There is a second insurer in this picture, and it plays by entirely different rules than the health plan. It may be able to pay for the rehab UnitedHealthcare is denying.
Texas law requires auto insurers to include Personal Injury Protection (PIP) on every policy unless the customer rejected it in writing (Tex. Ins. Code §1952.152). Many Texans have it and don't realize it. Courts read that rejection requirement strictly — absent a signed written rejection, PIP exists as a matter of law.
PIP pays medical expenses regardless of who was at fault. And here is the part that matters most:
PIP is not bound by Medicare's rules, the plan's medical necessity criteria, prior authorization, visit caps, or networks.
A denial from UnitedHealthcare has no bearing on PIP's obligation to pay. PIP can fund the physical therapy the plan is refusing.
| Typical limits | $2,500 minimum offer; commonly $5,000 or $10,000; some carriers write up to $100,000 |
|---|---|
| What it covers | Necessary medical, surgical, x-ray, nursing, hospital, and ambulance services — plus 80% of lost income |
| Fault | Irrelevant. Paid regardless. |
| Coordination with health insurance | Paid without regard to any other source of benefits |
| Do you have to pay it back? | Generally no. Under §1952.155 the PIP insurer generally cannot subrogate — meaning it is not recovered out of any later settlement. |
| Payment deadline | The insurer must pay within 30 days of satisfactory proof of claim |
The policy may require proof of loss within as little as six months of the accident. And expenses must be incurred within three years of it. If PIP is on the policy, file the claim now rather than after the appeals play out.
Medical Payments coverage works much the same way — medical expenses only, no wage replacement. But MedPay's subrogation treatment is policy-specific and is not protected by the statutory bar that covers PIP. Read the actual policy language before relying on it.
Federal Medicare Secondary Payer law makes the auto insurer primary: PIP/MedPay pays first, then the health plan. Providers are supposed to bill the auto coverage before the plan. One trap worth watching: providers who learn there's an auto claim sometimes refuse to bill the health plan at all and instead take a "letter of protection," waiting for a settlement. That usually hurts the patient, converting covered care into settlement-reducing debt at undiscounted rates. Insist providers bill PIP first, then the plan.
If there is a liability claim or settlement from the crash — from the at-fault driver, or from uninsured/underinsured motorist coverage — the Medicare Advantage plan has recovery rights against it.
MA plan liens are harder to deal with than ordinary Medicare liens, because they are not in the federal conditional-payment tracking system. There's no single portal, no standard letter process, no clear appeal path. They are often called "hidden liens" because they surface after settlement, when it's too late to account for them.
What to do:
A Texas personal injury attorney handles all of this routinely — PIP claims, the UIM timing problem, and lien resolution — and typically works on contingency, so there's no upfront cost to a consultation. Two reasons not to delay: Texas has a two-year statute of limitations on personal injury claims, and the PIP proof-of-loss window may be much shorter than that.
If you'd prefer to start without a lawyer, the two immediate steps are entirely doable yourself: pull the declarations page to see whether PIP exists and at what limit, and call the auto insurer to open a PIP claim.
You may encounter the term "Medicare set-aside." That's primarily a workers' compensation construct, and there's no formal federal review process for liability cases. What's actually needed here is lien resolution, not a set-aside — though future crash-related medical needs are still worth analyzing before settling anything.