Medicare Compensation Recovery information for insurers

Before paying someone compensation, you are required by law to tell us and pay any amounts payable to the Commonwealth.

From 2 June 2016, Section 23(6) of Health and Other Services (HOSC) Act has been amended and a claimant will no longer be required to sign a Notice of judgement or settlement form. Only the notifiable person will be required to sign.

About a compensation payment

For information for the injured person read the Medicare Compensation Recovery information for claimants.

When you need to tell us

The Health and Other Services (Compensation) Act 1995 (the Act), applies when a person receives 2 types of payments for an injury or illness:

  • those from eligible benefits provided through Australian Government programs including:
    • Medicare benefits
    • nursing home benefits
    • residential care subsides
    • home care subsidies, and
  • those from an awarded compensation payment where another party is liable for the relating treatment or care costs

In accordance with the Act, the compensation payer, usually the insurer, must tell us:

  • 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 6 months from the date the claim was made

You must tell us about the:

  • judgment
  • settlement, and
  • reimbursement arrangement

If you don’t tell us, you may be liable for any outstanding amount owing to the Commonwealth.

Where the agreed settlement or reimbursement arrangement must be filed with a court or other institute for it to be formally effected or sanctioned, this date is to be used as the date of settlement.

How to tell us

You can tell us by completing a Notice of Judgment or Settlement form or a Notice of reimbursement arrangement form.

Attach any relevant information asked for on the form. Make sure the form has been signed by you. Return the form to us within 28 days from the date the judgment, settlement or reimbursement arrangement was made.

The compensation payment should not be released to the claimant until you have paid us an advance payment or the Notice of past benefits or charge for any:

  • Medicare benefits
  • nursing home benefits
  • residential care subsides, or
  • home care subsidies

Send the completed form to us by post, fax or email.

When you don’t need to tell us

You are not obligated to tell us about the payment if either the:

  • total amount of compensation awarded including all costs is less than $5,000, or
  • the date the reimbursement arrangement was made is less than 6 months from the date the claim was made in writing

You are not required to notify us if the claimant is either:

  • an overseas visitor without a Medicare card, or
  • an Australian citizen who does not have a Medicare number, even if they attended a hospital for services

Email: Department of Social Services to find out whether there are any nursing home benefits, residential care or home care subsidies relating to the compensable injury or illness that need to be repaid.

Payments

Amount of eligible benefits that need to be repaid

You, the claimant or their authorised representative can find out the amount of eligible benefits that need to be repaid by requesting a Medicare history statement. A Medicare history statement will be given to the claimant to be completed and returned to us.

A Medicare history statement for Medicare compensation recovery is not the same as a Medicare history statement that you can request for other purposes.

The Medicare history statement lists each service the claimant has received a Medicare benefit for since the date of their injury or illness. The claimant can indicate the injury or illness by ticking the check box relating to the compensable injury or illness.

The statement can be requested as many times as needed and is provided with a declaration form to verify those services and declare whether nursing home benefits, residential or home care subsidies relate to the compensable injury or illness.

How to request a Medicare history statement

You, the claimant or their authorised representative can request a statement by completing and sending us the Request for a Medicare History Statement form.

No matter who requests the statement, it will only be sent to the claimant or their authorised representative.

We will send the claimant a Medicare history statement and a declaration form. The claimant can fill in a Compensation Recovery Program Third party authority form if they would like someone else to deal with their case.

The claimant needs to identify the services on their statement that relate to the compensable injury and return it and a declaration form to us within 28 days. If they don’t, or deliberately provide misinformation, it may result in all listed services on their statement applied as relating to their compensable injury or illness.

We will assess the information and reconcile the total amount of eligible benefits paid. We will then give you a Notice of past benefits and send a copy to the claimant.

The difference between a Notice of past benefits and Notice of charge

A Notice of past benefits lists the services identified and the total amount of eligible benefits paid, if any. If judgment or settlement for the compensation claim occurs within 6 months of the notice being issued, it will become the Notice of charge.

A notice after notification of the judgment, settlement or reimbursement arrangement is a Notice of charge. This can be issued to either:

  • you to pay the amount specified
  • the claimant where an advance payment has been made and an amount is still outstanding

In accordance with privacy principals, where all services on a Medicare history statement are applied as relating to the compensable injury or illness, the notice will specify the total amount of eligible benefits paid and not list the services.

The claimant has 2 years from the date of judgment or settlement to make an application to us requesting a review of the services applied and the amount paid from the compensation awarded.

Fixed medical, care costs or apportionment of liability

Where evidence is provided that a judgment or settlement has either:

  • fixed the amount of past medical or care expenses, we would adjust the amounts accordingly
  • specified that liability be apportioned between the parties, we would reduce the amount payable by the proportion of liability

Making payments to us and the claimant

It is an offence to pay the claimant any part of the compensation awarded unless any of the following applies:

  • you have paid us the amount specified in the Notice of charge
  • you have withheld that amount from the claimant
  • you have paid us an advance payment

Where a Notice of past benefits becomes a Notice of charge, the amount of past benefits is known. You must pay us the amount specified within 28 days of the date of judgment or settlement.

Where no Notice of past benefits is given within the 6 months before the judgment or settlement date, at the time of notification you may either:

  • request a Notice of charge be issued and pay us the amount specified within 28 days from the date of issue, or
  • pay us an advance payment of 10% of the total amount of compensation awarded within 28 days from the date of judgment or settlement

You can then pay the balance of the compensation to the claimant.

Where it is determined the amount owing is less than the advance payment amount, we will refund the balance to the claimant within 28 days. If the amount owing is more than the advance payment amount, the claimant is liable to pay the difference to us within 28 days.

An advance payment cannot be made if there is a valid Notice of past benefits

Compensation forms list

You may need these forms for Medicare Compensation Recovery:

Contact us if you need help completing the forms or need more information about Medicare Compensation Recovery.

Centrelink Compensation Recovery

Recovery of Australian Government payments through Centrelink is managed differently to Medicare payments.

If the claimant receives Australian Government payments through Centrelink, a compensation payment could affect the amount they are entitled to receive or past payments may need to be repaid.

You also have to tell us about the compensation payment, no matter what the amount.

Read more about Centrelink Compensation Recovery.

Page last updated: 15 September 2016

This information was printed Sunday 25 September 2016 from humanservices.gov.au/business/services/medicare/medicare-compensation-recovery-information-insurers It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.