Medicare and Medicaid Liens on an Ohio Injury Settlement

By the FigureMyTax Editorial Team · How we calculate

Ohio Medicaid has an automatic right of recovery. Reasonable attorney fees up to one-third, plus costs, come off first, and there is a rebuttable presumption that Medicaid receives no less than one-half of what remains or its actual payment, whichever is less. Medicare recovers under federal rules.

The right of recovery

R.C. 5160.37(A) says enrollment gives the department an automatic right of recovery against third-party liability for the cost of assistance paid, and any settlement, compromise, award or judgment is subject to it. The claim does not exceed what the department paid, except for managed care recipients, for whom it is the amount the managed care organization paid or would have paid.

Fees, costs and the presumption

The right does not reach attorneys' fees, costs or other expenses of securing the recovery, or medical expenses you paid from your own resources. Reasonable attorney fees up to one-third of the total, plus costs, are deducted first. Then it is rebuttably presumed the department receives no less than one-half of the remainder, or its actual payment, whichever is less. You may rebut it at a hearing by clear and convincing evidence, and the amount sought is held in escrow until the decision.

Notice

You or your attorney must give written notice within 30 days after starting informal recovery or filing a claim, and no settlement may be made final without notice and a reasonable chance for the department to perfect its rights. If it is not given, you and your attorney can be liable to reimburse the department up to what it paid.

Federal limit and Medicare

In Arkansas Department of Health and Human Services v. Ahlborn (2006), the U.S. Supreme Court held that Medicaid may reach only the portion of a settlement that represents medical costs. Under the Medicare Secondary Payer statute, 42 U.S.C. 1395y(b)(2), the United States may recover conditional payments and collect double damages from responsible entities; 42 CFR 411.24 governs recovery, and 42 CFR 411.37(c) reduces Medicare's recovery by its procurement-cost share. On a $100,000 settlement with $36,333 of fees and costs, $15,000 of Medicare payments would shrink to about $9,550.

Next steps

See how provider bills differ from liens and why health plans face a pro rata rule in Ohio, then enter every claim in the Ohio medical lien calculator.

This is general information, not legal advice, and the state comparisons above are illustrative, not an exhaustive survey. Confirm how Ohio's rules apply to your specific case with a licensed Ohio attorney.