Medicare and Workers' Compensation Interactions: Essential Information to Understand
Rewritten Article:
Dealing with Medicare and workers' compensation can be a tricky business. Failure to report a workers' comp arrangement could lead to claim denials and the need to repay Medicare.
Workers' comp is insurance for folks who've suffered job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor handles this benefit for federal employees, their families, and other specified entities.
If you're already on Medicare or soon will be, it's essential to grasp how your workers' comp benefits might affect Medicare's coverage of work-related medical bills. This understanding helps prevent complications with medical costs for work-related injuries.
How does a workers' comp settlement affect Medicare?
Under Medicare's secondary payer policy, workers' compensation should cover any treatment related to a work injury before Medicare steps in. But, if emergency medical expenses crop up before the workers' comp settlement, Medicare might pay first and implement a recovery process run by the Benefits Coordination & Recovery Center (BCRC). To steer clear of a recovery process, the Centers for Medicare & Medicaid Services (CMS) keeps track of the amount a person receives from workers' comp for their injury-related medical care.
Sometimes, Medicare requests the creation of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only pay for treatment after all the WCMSA funds have been used up.
What settlements need to be reported to Medicare?
Workers' comp companies must submit the Total Payment Obligation to the Claimant (TPOC) to CMS so Medicare can cover the appropriate portion of an individual's medical expenses. This TPOC reveals the total amount owed from workers' comp to the person or on their behalf.
If a person is currently on Medicare due to age or receiving Social Security Disability Insurance, and the settlement is $25,000 or more, a TPOC is required. Furnishing a TPOC is also necessary if the person won't be on Medicare yet 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 report to Medicare if they file liability or no-fault insurance claims.
Frequently Asked Questions
Questions about Medicare can be answered by phoning 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is available on Medicare.gov. If you have questions about the Medicare recovery process, reach out to the BCRC at 855-798-2627 (TTY 858-598-2627).
A WCMSA is voluntary, but it's needed if a workers' comp settlement is $25,000 or more (or $250,000 or more if you'll be on Medicare within 30 months). Misusing WCMSA funds for purposes other than their designated use can lead to claim denials and reimbursement obligations.
Insight: To guarantee proper Medicare coverage and reduce reimbursement obligations, Medicare beneficiaries should report workers' comp settlements as required, establish WCMSAs as needed, and properly document and manage their WCMSAs. Employers and insurance companies should revise and update internal processes for WCMSA settlements, provide training to claims adjusters and legal teams, and monitor CMS updates regularly to remain compliant. By following these steps, beneficiaries can avoid claim denials and reimbursement obligations linked to workers' comp settlements.
- Navigating Medicare and workers' compensation can be complex, potentially resulting in claim denials and the need for Medicare repayment due to unreported workers' comp arrangements.
- Workers' compensation is a type of insurance for individuals who have experienced job-related injuries or illnesses, and the Office of Workers' Compensation Programs (OWCP) under the Department of Labor handles this benefit for specified entities including federal employees and their families.
- When it comes to Medicare, understanding how workers' comp benefits can impact Medicare's coverage of work-related medical expenses is crucial to prevent complications with medical costs associated with work-related injuries.
- Medicare's secondary payer policy states that workers' compensation should cover treatment related to a work injury before Medicare gets involved, but emergency medical expenses paid by Medicare before workers' comp settlement may require reimbursement through the Benefits Coordination & Recovery Center (BCRC).
- In order to avoid a recovery process, the Centers for Medicare & Medicaid Services (CMS) keeps track of the amount received from workers' comp for injury-related medical care, and sometimes requests the creation of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds.
- Workers' comp companies must submit the Total Payment Obligation to the Claimant (TPOC) to CMS if a person is on Medicare due to age or receiving Social Security Disability Insurance, or if they will qualify for Medicare within 30 months, and the settlement is $25,000 or more (or $250,000 or more in the latter case).
- Reporting workers' comp settlements, WCMSAs, and other applicable insurance claims to Medicare is essential not only for Medicare beneficiaries to maintain proper coverage but also for employers and insurance companies to remain compliant, avoiding claim denials and reimbursement obligations that may result from non-compliance.
