Medicare and workers' compensation: Essential information to understand
Rewritten Article:
Hey there! It's essential to inform Medicare about workers' compensation arrangements to avoid trouble with claim denials and having to repay Medicare. Here's what you need to know.
Workers' compensation is an insurance program for people who have suffered work-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor is responsible for this benefits, which protect federal employees, families, and other entities.
Now, let's talk about how workers' compensation affects Medicare when someone is already enrolled orabout to be enrolled in Medicare. To prevent complications with medical costs for work-related injuries, it's crucial to understand the connection between these two systems.
How does a workers' comp settlement impact Medicare?
Under Medicare's secondary payer policy, workers' compensation must cover the initial treatment for a work-related injury before Medicare kick in. If immediate medical costs arise before you receive the workers' compensation settlement, Medicare may pay first and start a recovery process handled by the Benefits Coordination & Recovery Center (BCRC).
To prevent ongoing recovery processes, the Centers for Medicare & Medicaid Services (CMS) keeps tabs on the funds received from workers' compensation for injury-related medical care. In certain cases, Medicare may ask for a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will cover the care only after all the money in the WCMSA is spent.
What settlements need to be reported to Medicare?
Workers' compensation must submit a total payment obligation to the claimant (TPOC) to CMS to make sure Medicare covers the appropriate portion of a person's medical expenses. This amount signifies the total amount of workers' compensation due to the person or on their behalf.
Reporting a TPOC is necessary:
- If a person is already enrolled in Medicare based on their age or based on receiving Social Security Disability Insurance, and the settlement is $25,000 or more.
- If the person is not enrolled in Medicare, but will qualify for the program within 30 months of the settlement date, and the settlement amount is $250,000 or more.
Apart from workers' comp, a person must also report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
Questions can be directed to Medicare by phone at 800-MEDICARE (800-633-4227,TTY 877-486-2048). During specific hours, there's also a live chat available on Medicare.gov. For questions about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is optional. However, if a Medicare beneficiary wants to set one up, their workers' compensation settlement must be over $25,000. Alternatively, it must be over $250,000 if they're eligible for Medicare within 30 months.
It's forbidden to use the money in a Medicare set-aside arrangement for any purpose other than the intended one. Misusing the funds can lead to claim denials and the obligation to repay Medicare.
"Learn more: What to know about Medicare set-asides## Takeaway
Workers' compensation insurance covers job-related injuries or illnesses for federal employees and certain groups.
Enrolled Medicare individuals or those about to join Medicare should educate themselves on how workers' compensation affects their Medicare coverage to prevent medical expense issues. It's vital to inform Medicare about workers' compensation agreements to avoid claim rejections and reimbursement obligations.
Medicare resources
For more guidance on the complex world of medical insurance, visit our Medicare hub.
- To avoid potential claim denials and reimbursement obligations, it's essential for Medicare enrollees or those about to enroll to understand how workers' compensation affects their Medicare coverage.
- Under Medicare's secondary payer policy, workers' compensation must cover the initial treatment for a work-related injury before Medicare steps in.
- Medicare may ask for a workers' compensation Medicare set-aside arrangement (WCMSA) to keep track of the funds received from workers' compensation for injury-related medical care.
- Workers' compensation must submit a total payment obligation to the claimant (TPOC) to Medicare if a person is already enrolled in Medicare based on their age or SSDI, and the settlement is $25,000 or more.
- If a 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, workers' compensation should also report the TPOC to Medicare.
- Misusing funds in a Medicare set-aside arrangement can lead to claim denials and the obligation to repay Medicare, making it important to use the funds only for their intended purposes.
