S26. Arrangement for payments to Medicare Australia

Commencement date: 21 October 2019

Proactive engagement with Medicare Australia and correct attribution of medical costs helps to ensure prompt payment of entitlements and reduces the risk that a worker will be inadvertently subject to recovery action from Medicare.

Principle

Due care will be given in the management of claims to mitigate risks arising from the interaction between Medicare and the workers compensation scheme.

ExpectationsBenchmarks
S26.1

Insurers are to consider whether to request a notice of past benefits from Medicare when:

  • an application for dispute resolution has been lodged with the Workers Compensation Commission (excluding disputes that only relate to work capacity decisions)
  • accepting liability for a condition that is contracted or caused by gradual process or that may be an aggravation of a disease
  • there is a retrospective entitlement to compensation (when liability for medical expenses had been disputed but subsequently accepted six months or more after the liability dispute date), or
  • a settlement of a claim for compensation is initiated that will exceed $5,000.

Where appropriate, Medicare notice of past benefits to be initiated within five working days of relevant event

Proactive advice to Medicare and correct attribution of the payment of medical costs, allows insurers to make prompt payment of entitlements and reduces the risk that a worker is inadvertently subject to recovery action from Medicare Australia.

The Health and Other Services (Compensation) Act 1995, applies when a person receives eligible benefits provided through Australian Government programs, including Medicare benefits

A Medicare request for notice of past benefits is required when a payment greater than $5,000 is likely and medical services for a work-related injury may have been paid by Medicare Australia.

The Health and Other Services (Compensation) Act 1995, applies when a person receives eligible benefits provided through Australian Government programs, including Medicare benefits.

In accordance with this Act, the compensation payer (usually the insurer) must tell the Department of Human Services:

  • within 28 days from the date of a judgment or settlement
  • when settlement fixes the value of compensation awarded at more than $5,000 including all costs, or
  • when a reimbursement arrangement is made more than six months from the date the claim was made.
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