Services Covered Under No-Fault Insurance Where Liability Claim Also Filed

40.4 – Services Covered Under No-Fault Insurance Where Liability Claim Also Filed (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) If injuries are covered under automobile, medical, or no-fault insurance, and the individual also files a claim against a third party for injuries suffered in the same accident, a claims determination must first be made by the automobile, medical, or no-fault insurer before a claim for Medicare benefits can be paid. A Conditional Medicare payment may be made to the extent that payment is not made under the automobile, medical, or no-fault insurance. The payment is subject to recovery if the individual later receives payment from a liability insurer. For example, an individual incurs $20,000 in covered medical expenses due to an automobile accident. The individual receives $5,000 in no-fault insurance benefits toward covered medical expenses and also has a liability claim pending against the driver of the other car. Medicare does not pay benefits for the $5,000 in expenses paid for by the no-fault insurer but pays conditional benefits based on the additional $15,000 in expenses. The Medicare payment is subject to recovery when the liability claim is paid (in other words, a settlement, judgment, award, or other payment has been received/made).