Medicare and Workers' Compensation Interactions: Essential Facts
No-BS Guide to Informing Medicare About Your Workers' Compensation
Let's cut to the chase, folks. If you've been injured on the job and got a sweet workers' comp settlement coming your way, you'll want to make sure you don't end up in a messy dispute with Medicare. Here's the lowdown.
First off, workers' comp is for those who've been hurt or fell sick on the job. The Office of Workers' Compensation Programs (OWCP), part of the Department of Labor, handles this insurance deal for federal employees, their families, and a few other lucky folks.
If you're currently munching on your Medicare benefits or are planning to soon (bye bye, retirement), be smart and understand how those workers' comp benefits could influence Medicare's coverage of your medical bills. Otherwise, you could get stuck trying to sort out medical expenses for job-related injuries or illnesses—the last thing you need!
So, what's the deal with workers' comp settlements and Medicare?
Under Medicare's secondary payer policy, workers' comp needs to cover the bill for any medical care related to your job injury. However, if immediate medical costs happen before your fat workers' comp check shows up, Medicare may pay first and start a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To stay away from a recovery process and complications with your expenses, the Centers for Medicare & Medicaid Services (CMS) keeps a close eye on how much you get from your workers' comp for your medical care due to the injury or illness. In some cases, Medicare might ask for a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover your medical bills after every penny in your WCMSA is used up.
What settlements need to be reported to Medicare?
When workers' comp dishes out a total payment obligation to the claimant (TPOC), they need to pass it along to CMS. This représ the total amount of workers' comp cash owed to you or on your behalf.
If you're an existing Medicare member because you've hit the golden age or are a recipient of Social Security Disability Insurance, and your settlement is $25,000 or more, you'll need to submit a TPOC to CMS.
If booking your ticket on Medicare’s Express is on the horizon within the following 30 months post settlement date, and the settlement amount is $250,000 or higher, then it also warrants a TPOC submission.
Additionally, you'll need to add the "file" of a liability or no-fault insurance claim to Medicare's list as well.
Got questions?
Questions, questions, questions! No worries. You can phone the helpful fellows at Medicare at 800-MEDICARE (800-633-4227,TTY 877-486-2048) or chat 'em up during certain hours on Medicares' digital haven, Medicare.gov. If you've got queries concerning the Medicare recovery process, the BCRC would love to hear from you at 855-798-2627 (TTY 855-797-2627).
FAQ
Contact Medicare with any question via phone at 800-MEDICARE (800-633-4227) or live chat through Medicare.gov during select hours. For questions about the Medicare recovery process, reach out to the BCRC at 855-798-2627.
A Medicare set-aside arrangement is voluntary, but if you desire to set one up, your workers' comp settlement must exceed $25,000 or $250,000 if you become Medicare-eligible within the next 30 months.
Absolutely! Using the cash from a Medicare set-aside arrangement for any purpose other than what it was intended for? Big no-no. Mishandling the money could result in claim denials and reimbursement obligations.
Key Takeaway
Workers' comp is a ticket out of medical debt if you sustain an injury or illness on the job.
If you're already tucking into Medicare or are ready to join the club, make sure you understand how workers' comp can affect your Medicare coverage to steer clear of expensive medical bills for job-related accidents.
Oh, and don't forget to give the honchos at Medicare a heads-up about your workers' comp arrangement!
Resources
For more juicy tips to help you navigate the complicated world of health insurance, swan over to our Medicare hub.
- If you have a workers' comp settlement and are also on Medicare, ensure Medicare's coverage of your medical bills is not affected by understanding the influence of the workers' comp benefits.
- For Medicare's secondary payer policy to work properly, workers' comp needs to cover medical care related to your job injury, and Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds.
- When workers' comp pays a total payment obligation to the claimant (TPOC), they should inform the Centers for Medicare & Medicaid Services (CMS) if the settlement is over $25,000 or if Medicare eligibility is about to be achieved within the next 30 months, and the settlement amount is over $250,000.
- Medicare's programs like workplace-wellness, health and wellness, fitness and exercise, and therapies and treatments can be essential parts of a Medicare set-aside arrangement, utilizing nutrition, science, and healthsystems to improve the claimant's long-term health outcome.
- Depending on the terms of your workers' comp settlement, you may be required to report it to Medicare to avoid any complications with your medical expenses and ensure Medicare will cover your bills only after every penny in the WCMSA is used up.
