Workers' Compensation Recovery

One of the principles of Medicaid is that the program pays for services only when no other entities are legally required to do so. If an individual has private health insurance to cover a cost, for example, Medicaid doesn't pay the amount.

This concept is sometimes referred to as Medicaid as "the payer of last resort," meaning that Medicaid only pays claims for covered items and services if there are no other liable third-party payers for the same items and services. This concept is implied in statute and regulation and has been cited by the U.S. Congress and the U.S. Supreme Court. The Social Security Act (the Act) requires that states take "all reasonable measures to ascertain the legal liability of third parties." The Act further defines third party payors to include, among others, health insurers, managed care organizations (MCOs), group health plans, liability insurance (including automobile, homeowners, and medical malpractice), indemnity plans, Workers' Compensation, and any other parties that are legally responsible by statute, contract, agreement, or judgement to pay for care and services.

Individuals must assign to the Medicaid program their rights to medical support and payment of medical care from a third party. The individual must assign his or her rights and cooperate in identifying and providing information to assist the state Medicaid agency in pursuing liable third parties. Individuals who are able and required to assign their rights to medical support and payment of medical care, but fail to do so, are not eligible for Medicaid, and a state Medicaid agency may not pay for any services for those individuals.

A Medicaid customer may need medical items or services due to an injury or illness that occurred at their job. The Workers' Compensation program is a long-established form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employees' right to sue his or her employer for the tort of negligence. In the state of Illinois, the Illinois Workers' Compensation Commission resolves disputes between employees and employers regarding work-related injuries and illnesses.

State Medicaid agencies must recover from Worker' Compensation settlements or court judgements (awards) that include compensation for medical expenses, since a third-party is liable for the cost of medical care provided to beneficiaries. In the state of Illinois, the Department of Healthcare and Family Services Bureau of Collections is responsible for coordinating these recoveries of Medicaid payments. These recoveries are used to help fund additional services to other Medicaid beneficiaries.

For additional information about recoveries related to Workers' Compensation cases, email us at the links below or write to:

Illinois Department of Healthcare and Family Services
Bureau of Collections - Technical Recovery Section
P.O. Box 19174
Springfield, Illinois 62794-9174

HFS.BOC.TRS.CHI.PI@illinois.gov

HFS.BOC.TRS.SPR.PI.WC@illinois.gov

We will need a copy of the signed HIPAA document, a letter of representation and the following information:

• Injured Party Name 
• Injured Party Date of Birth
  
• Last four digits of Social Security Number
• State of Illinois Medicaid Case Number, if available
• Medicaid Recipient Number, if available
• Date of Accident
• Type of Accident
• Treatment End Date
• Injured Part of the Body
• Employer's Name
• Employer's Address
• Signed copy of Workers' Compensation contract authorizing the release of medical records

*If injured party is a minor, we will need the Guardian's full name, last four digits of their social security number and their date of birth.