OMIG, on behalf of the New York State Medicaid program, is required by federal and state law to identify any liable third party who may be responsible for paying the medical expenses of a Medicaid recipient for treatment related to an accident or injury. This includes seeking repayment from applicable insurance carriers and liable parties in personal injury settlements. If a Medicaid recipient is injured and receives a settlement because of that injury, relevant funds are subject to recovery by Medicaid for any amount Medicaid paid for the treatment of injuries sustained.
OMIG pursues recovery against liable third parties by filing a 104-b lien with the court system against the personal injury settlement for the cost Medicaid paid related to the injuries sustained by the Medicaid recipient.
FREQUENTLY ASKED QUESTIONS
This FAQ is also available as a PDF for Download.
1. What is Medicaid Casualty Recovery?
OMIG is required to review instances when an individual who is, or has been, enrolled in Medicaid has an accident or injury. OMIG is required by federal and state law to pursue recovery from any liable third party who may be responsible for paying the medical expenses related to that Medicaid recipient’s injury. This includes seeking repayment from applicable third parties such as insurance carriers and personal injury settlements.
2. How does Medicaid recover?
OMIG will work with any responsible insurance carriers for repayment. If payment is denied by the insurance carrier, OMIG is required to pursue recovery from any potential settlement related to the injury. In order to recover, a “Notice of Lien” may be filed with the local county clerk and/or lien statements may be sent to the recipient and/or the recipient’s attorney. A lien is not filed on any property or assets aside from the settlement proceeds related to the accident.
3. What about Medicaid Managed Care enrolled recipients? What is a capitation payment?
A capitation payment is the monthly amount paid to a Medicaid Managed Care Organization (MCO) for each Medicaid recipient’s care. This amount is not always reflective of the actual cost of services provided to that recipient each month. If a recipient who is enrolled in Medicaid through an MCO, sustains injuries in an accident, and pursues litigation relevant to that accident, the capitation payment paid by Medicaid to the MCO for that recipient is subject to recovery if any treatment for the accident occurred in that month.
4. How is the lien amount determined?
Claims paid by New York State Medicaid are reviewed to determine which services were for treatment related to injuries stemming from the accident. The total paid by New York State Medicaid toward these services is the lien amount, which is subject to change as claims accrue. If a recipient is enrolled through an MCO, the capitation payment for any months in which related treatment is provided must be included.
5. Can the Medicaid lien be paid prior to settlement?
Medicaid liens should not be paid while the recipient plaintiff is continuing to receive treatment for injuries related to the accident as claims may continue to accrue prior to settlement. Interim Statements of Aid Paid will be provided, and can be requested, until time of settlement. This is not a final lien amount, and a final lien amount must be requested at time of settlement.
6. What if the settlement is not high enough to satisfy the lien?
If the settlement isn’t large enough to satisfy the Medicaid lien, a lien reduction or compromise can be requested. A Final Statement of Aid Paid must be requested and received prior to requesting a reduction. Lien reduction requests must be submitted in writing and must contain a full settlement breakdown, including any other liens. If a reduction is being requested based on an insufficient settlement amount, settlement examples of similar cases which support your asserted case value should be provided. Please note that there is no provision for a reduction for attorney’s fees, costs, and expenses.
7. What about suits against Nursing Homes?
If a recipient has a suit against a nursing home, Medicaid cannot assert a lien on the settlement. If the recipient passes away, settlement proceeds from the suit may become part of the estate and could be subject to recovery.
8. What if the Medicaid recipient plaintiff in a personal injury suit passes away?
If the recipient was under the age of 55 when they passed away and not permanently institutionalized, recovery against the insurance company or settlement proceeds for their personal injury suit will be pursued as a casualty recovery.
When a Medicaid recipient passes away at 55 years of age or older, or if they were permanently institutionalized, OMIG is required by federal and state law to seek reimbursement for certain medical costs paid by Medicaid for the recipient’s care against any assets they may have in their estate. When a recipient who is a plaintiff in a personal injury suit passes away, the settlement may become part of their estate. A Medicaid claim placed on the estate may contain additional charges not related to the accident and can encompass up to 10 years of Medicaid paid costs. Unlike Casualty liens, Estate claims cannot be reduced or compromised, but they are subject to Deferral, Exemption, and Undue Hardship consideration.
9. How is the lien released?
Once payment has been received, a Release of Lien will be filed with the local county clerk and/or a letter will be provided to the recipient and/or recipient’s attorney advising that the lien has been satisfied.
10. How does OMIG’s contract vendor assist with personal injury settlements (casualty) recovery?
OMIG’s contract vendor will send letters, contact recipients and/or their attorneys for information, provide information to support the local county attorneys who appear in court on behalf of the State, and take calls from recipients, their representatives, and other stakeholders about the program in general and about specific cases.
11. I am represented by an attorney can I contact the vendor directly?
No, if you are represented by an attorney information can only be disclosed to your attorney.
12. Why did I receive a letter from Health Management Systems (HMS)? Who are they?
New York State OMIG contracts with a vendor to perform certain casualty and estate recovery tasks. Currently, the vendor is HMS. Their main office is currently located in Texas, but they have offices in Albany, New York as well.
13. I was not in an accident, but I received a Notice of Intent to File a Lien letter and questionnaire. What do I do?
Information that will prompt the issuance of a Notice of Intent to File a Lien comes from many sources. If there was no accident, please indicate that on the form and return it.
14. I am not on Medicaid, but I received a Notice of Intent to File a Lien letter and questionnaire. What do I do?
Please fill out the form to the best of your ability and return it. Information that will prompt the issuance of a Notice of Intent to File a Lien comes from many sources. OMIG is required to review instances when an individual has an accident or injury, and that individual is, or ever has been, enrolled in Medicaid, even if that individual never used their Medicaid coverage or if they are not currently eligible for Medicaid.
Related Casualty & Estate Recovery Resources
- Overview
- Regulatory Authority (updated November 2024)
- Estate Recovery (updated November 2024)
- TEFRA (updated November 2024)
- Contact Information