Texas Department of Insurance Issues Letter to CMS Regarding Improper Denials of Payment to Medicare Beneficiaries

On July 31st, the Commissioner of the Division of Workers’ Compensation for the Texas Department of Insurance (TDI), Rod Bordelon, issued a letter to Marilyn Tavenner, the Administrator at CMS regarding CMS improperly denying payment to Medicare beneficiaries. A copy of the letter can be found here.

In the letter, Bordelon states that TDI has been receiving numerous complaints from Medicare beneficiaries that they have been denied medical coverage by CMS due to the fact that the beneficiary had a previous workers’ compensation claim. In response, CMS has been asking TDI to confirm that the beneficiary’s prior workers’ compensation claim has been closed/settled so that the injured employee could seek medical treatment through Medicare. TDI cannot confirm that workers’ compensation claims are “closed or “settled” since under Texas state law, medical benefits for workers’ compensation claims are unable to be settled (Texas Labor Code, §408.005(b) and §408.021(d)).

Bordelon goes on to state in his letter that there is little policy guidance available for RREs to address situations where state workers’ compensation laws prohibit claim settlements for medical benefits (and therefore prohibit claims to be “closed” for future medical benefits. He therefore urges CMS in his letter to issue additional policy guidance to RREs on how to address situations, like these, where state laws prohibit the settlement of medical benefits for workers’ compensation claims.

In essence, there has to be better communication between CMS and RREs, and this issue needs to be addressed as this is creating unnecessary hurdles for Medicare beneficiaries who urgently need access to medical care for non-work related conditions. When looking at this issue, CMS should not only look to Texas, but other states as well where similar issues are occurring.

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