Medicare Compensation Recovery information for claimants
Your compensation payer must tell us if you get a compensation payment of more than $5,000 in case you were also paid other benefits for your injury.
You need to know
A compensation payment is an amount of money paid to someone because they have an injury or illness caused by the negligence or lack of care by another person.
The payment is usually made by an insurance company, but it can also be made by an individual or another company.
If your judgment or settlement is for more than $5,000 including all costs the compensation payer must tell us, in writing, within 28 days of the decision.
The insurer, or person paying you can tell us by sending us a Medicare Compensation Recovery Notice of Judgment or Settlement form.
Compensation payers should read the Medicare Compensation Recovery information for insurers.
If the compensation amount is less than $5,000, including all costs, or the date the reimbursement arrangement was made is less than 6 months from the date your claim was made, you don’t need to tell us. You don’t need to repay any past Medicare benefits, nursing home benefits, residential care or home care subsidies to us.
Read more about Medicare Compensation Recovery information for insurers.
Nursing home benefits, residential care or home care subsidies related to your compensation injury must be repaid to us when your claim reaches judgment or settlement and is for more than $5,000 including all legal costs.
This is only when your claim reaches judgment or settlement and is for more than $5,000 including all legal costs.
Nursing home benefits, residential care and home care subsidies are paid by the Department of Health.
You must tell us if you have received these benefits or subsidies when you complete the declaration that comes with:
The declaration requires you to tell us:
- whether you were admitted to a nursing home or residential care facility, or received home care, for treatment of the injury or illness you received as part of your compensation claim, and
- the name of the facility you were admitted to
If you disagree with the amount of nursing home benefit, residential care or home care subsidy identified in your Notice of past benefits, you can request a review by writing to us. You may be asked to provide medical evidence from your treating medical practitioner, who must specify:
- that the nursing home residency doesn’t relate to the compensable injury, or
- the percentage of nursing home residency that relates to your injury
All requests for review will be forwarded to the Department of Health for decision.
You can find out the amount that will need to be repaid before you accept a compensation payment, called a settlement.
When your claim reaches judgment or settlement, you will receive a compensation payment for your injury or illness.
If your claim is finalised by way of judgment or settlement, and you have a Notice of past benefits that has not expired before the date of judgment or settlement, the compensation payer must:
- send the amount on the Notice of past benefits to us, and depending on your settlement agreement or the judgment findings, the amount may be taken out of the total amount of compensation to be paid to you, and
- send the remaining balance to you
If you were given a Notice of past benefits and it expired before your claim is settled, you can either:
- ask for a new Medicare history statement so you can identify the services paid to you since the last Notice of past benefits was given to you - when this is completed and returned, we will send a new Notice of past benefits to the person paying your compensation so that they can repay the new amount
- if you haven’t been paid any more Medicare benefits, nursing home benefits, residential care or home care subsidies since the last Notice of past benefits was given, you can confirm this by sending us a declaration, known as a Section 23A statement and declaration, with the settlement documents, or
- the compensation payer can give us an advance payment of 10% of your total settlement amount and release the remaining 90% to you – if the amount to be paid to the department is more than the 10% advance payment, you will be responsible for paying the outstanding amount
If the advance payment option is not chosen, the person paying your compensation can’t give you any settlement money until we have been repaid in full.
An Advance payment is a payment made by the compensation payer which is equal to 10% of the total amount of compensation paid by judgment or settlement.
This option can only be taken when there is no valid Notice of past benefits at the time of judgment or settlement, and when the compensation payment is more than $5,000 including all costs.
By law, this must be sent to us within 28 days of judgment or settlement. If the compensation payer chooses to use the advance payment, they must tell you in writing:
- the amount that will be sent to us
- why the Australian Government can retain some or all of the advance payment
- that you are responsible for paying the difference between the advance payment and the amount due to the Australian Government if the advance payment doesn’t cover the amount payable
When the advance payment is taken, we’ll send you a Medicare history statement. You must complete and return the statement within 28 days so we can calculate the amount, if any, to be repaid.
If the amount due is less than the advance payment amount, we’ll refund the balance to you. This will generally be within 3 months of receiving the advance payment and completed documents from the compensation payer, whichever is received last.
It may take longer than 3 months to refund any balance to you if you’ve been:
- granted an extension, or
- asked to review your Medicare history statement
Read more about Medicare Compensation Recovery information for insurers.
By law, the person paying the compensation, usually the insurance company, must tell us in writing when a claim for compensation reaches judgment or settlement.
If the compensation amount is more than $5,000 including all costs they must:
- tell us in writing within 28 days of the date of judgment or settlement
- give us a completed and signed Medicare Compensation Recovery Notice of Judgment or Settlement form
You must give us written permission if you want information about your compensation case sent to a third party, such as your solicitor.
This includes Medicare benefits or the amount to be repaid to us.
Complete the Medicare Compensation Recovery Third party authority form and send it to us, so that we can talk to a third party about your compensation case.
You will need to submit forms to us about your compensation case. You may also want to enquire about your case.
Write, email or fax the Medicare Compensation Recovery team to submit a form or enquire about your compensation claim.
Sometimes you may not be able to tell us about your judgment or settlement until after it occurs.
If you can’t notify us until after the judgment or settlement is reached because you don’t know the amount to be repaid and we haven’t given you a Notice of past benefits:
- you, your solicitor or insurer can ask us to give you a Medicare history statement so that you can identify the amount you need to pay to us - you can’t be paid your compensation until this amount is known, or
- the person paying your compensation can choose to make an advance payment to us, which is currently 10% of the final settlement amount and the remaining 90% can then be given to you – if the amount to be repaid to us is more than the 10% advance payment, you will be responsible for paying the extra amount
If an amended Notice of past benefits has been sent to you, you have 2 years from the date your compensation case settled to ask for a review of this amount.
To request a review write email or fax the Medicare Compensation Recovery team.
We may ask you to confirm why:
- all of the services listed in the Notice of past benefits weren’t related to your compensable injury or illness, and
- the Medicare history statement wasn’t completed and given to us as required under the Health and Other Services (Compensation) Act 1995
If we are satisfied that a review can be done, a new Medicare history statement will be issued to you to complete and return within 28 days for assessment.
A new Notice of past benefits will be issued to you telling you the new amount to be paid. If this is less than what has already been paid then a refund will be made.
If at the time your compensation case settled:
- an advance payment was received, any refund will be made directly to you
- the Notice of past benefits was valid, and the amount on the notice was paid by the compensation payer, any refund will be made to the compensation payer, unless they’ve authorised us to return it to you
If you are not happy with our decision or if we don’t accept your request for review, you can choose to apply to the Administrative Appeals Tribunal for a review of our decision. Contact the Administrative Appeals Tribunal to discuss your situation at:The Administrative Appeals Tribunal
GPO Box 9955
In your capital city
When you return your completed Medicare history statement, we must confirm that the correct services have been identified.
If we think that you may have missed services for your injury or illness, we are required by law to send you a letter asking you to review your Medicare history statement again and return it to us within 28 days. If we don’t receive a revised statement back from you by the due date, or if we think the services relating to your injury or illness have still not been identified, then all services on the Medicare history statement will be counted or deemed as relating to the injury.
Deemed means that all services listed on your Medicare history statement are considered as being related to your compensation claim and you will need to repay the amount of all the listed services to us.