Medicare and Workers' Compensation Claims: An Overview of Key Facts
It's essential to keep Medicare in the loop when it comes to workers' compensation arrangements. Neglecting to do so could lead to claim denials and having to foot the bill yourself.
Workers' comp is the insurance that covers employees who get hurt or sick on the job. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor handles this benefit for federal employees, their families, and various other entities.
Those currently enrolled in Medicare or soon to be should thoroughly understand how workers' compensation may influence Medicare's coverage of medical claims. This knowledge will help them avoid complications when it comes to covering work-related injuries or illnesses.
So, how does a workers' comp settlement impact Medicare?
Medicare, being a secondary payer, should ideally be the primary source of payment for any treatment related to a work-related injury, as per the Medicare Secondary Payer policy. However, if immediate medical expenses surface before the workers' comp settlement is received, Medicare might pay first and initiate a recovery process overseen by the Benefits Coordination & Recovery Center (BCRC).
To avoid such a recovery process, the Centers for Medicare & Medicaid Services (CMS) often keeps track of the amount people receive in workers' comp for their injury or illness-related medical care. In some instances, Medicare may request that a workers' compensation Medicare set-aside arrangement (WCMSA) be established for these funds, so that Medicare will only pay for care after the WCMSA has been depleted.
What settlements should be reported to Medicare?
Workers' comp is required to submit a Total Payment Obligation to the Claimant (TPOC) to the CMS to ensure Medicare covers a fair share of a person's medical expenses. This TPOC represents the total sum of workers' comp that is owed to the person or on their behalf.
A TPOC must be submitted if a person is already enrolled in Medicare based on their age or SSDI, and the settlement is $25,000 or more, or if the person is not enrolled in Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more.
In addition to workers' comp, a person must also report to Medicare if they file a liability or no-fault insurance claim.
Got questions?
You can reach out to Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or during certain hours via the live chat on Medicare.gov. For questions about the Medicare recovery process, you can contact the BCRC at 855-798-2627 (TTY 855-797-2627).
It's important to know that a Medicare set-aside is optional, but if a Medicare beneficiary opts to set one up, their workers' comp settlement must be over $25,000, or over $250,000 if they are eligible for Medicare within 30 months.
Moreover, it's crucial to remember that the funds in a Medicare set-aside arrangement should be used solely for the purpose designated, otherwise, claim denials and reimbursement to Medicare may be the consequence.
Takeaway
In short, workers' compensation is a lifeline for people with job-related injuries or illnesses among federal employees and others.
It's vital for those enrolled in Medicare or soon to be to familiarize themselves with how workers' compensation might impact their Medicare coverage to ward off issues in relation to medical expenses. Reporting workers' compensation agreements to Medicare is also crucial to sidestep future claim rejections and reimbursement obligations.
- The Centers for Medicare & Medicaid Services (CMS) often keeps track of the amount people receive in workers' comp for their injury or illness-related medical care, and in some instances, Medicare may request that a workers' compensation Medicare set-aside arrangement (WCMSA) be established.
- A Total Payment Obligation to the Claimant (TPOC) must be submitted to the CMS if a person is already enrolled in Medicare based on their age or SSDI, and the settlement is $25,000 or more, or if the person is not enrolled in Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more.
- It's important to know that a Medicare set-aside is optional, but if a Medicare beneficiary opts to set one up, their workers' comp settlement must be over $25,000, or over $250,000 if they are eligible for Medicare within 30 months.
- More than just workers' comp, a person must also report to Medicare if they file a liability or no-fault insurance claim.
