Medicare Impact on Workers'compensation Benefits: Key Insights
Working With Medicare and Workers' Compensation: What You Need to Know
Navigating the intersection of Medicare and workers' compensation can be a tricky business, especially when it comes to reporting settlements. Ignoring this process could lead to trouble down the line, with potential claim denials and hefty reimbursement obligations.
Workers' Compensation Explained
Workers' compensation is insurance that covers employees who suffer injuries or illnesses directly related to their jobs. This benefit is overseen by the Office of Workers' Compensation Programs (OWCP), a division of the Department of Labor. It caters to federal employees, their families, and certain other entities.
The Interplay Between Medicare and Workers' Compensation
For workplace-related injuries or illnesses, workers' compensation should be the primary payer for medical treatment. Medicare, however, may step in if costs arise before the workers' compensation settlement is secured. In such cases, Medicare might initiate a recovery process handled by the Benefits Coordination & Recovery Center (BCRC).
To prevent recovery processes and better manage costs, the Centers for Medicare & Medicaid Services (CMS) often monitors the amount received from workers' compensation for injury- or illness-related medical care. In some instances, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds, only covering care after the WCMSA is exhausted.
What Settlements Require Reporting to Medicare?
Workers' compensation must submit a Total Payment Obligation to the Claimant (TPOC) to CMS to ensure Medicare covers its portion of medical expenses. This reporting is mandatory when:
- A person is already enrolled in Medicare due to age or Social Security Disability Insurance, and the settlement is $25,000 or more.
- The person is not yet enrolled in Medicare but will be within 30 months of the settlement date, and the settlement is $250,000 or more.
Additionally, individuals must report liability or no-fault insurance claims to Medicare.
Frequently Asked Questions
To get answers to your questions about Medicare and workers' compensation, you can call Medicare at 800-MEDICARE (800-633-4227), or use the live chat on Medicare.gov during specific hours. For questions about the Medicare recovery process, contact the BCRC at 855-798-2627.
The Role of the WCMSA
A WCMSA is voluntary, but it becomes necessary when the workers' compensation settlement exceeds $25,000 (or if the person is eligible for Medicare within 30 months and the settlement is $250,000 or more). Misusing WCMSA funds for unauthorized purposes can lead to claim denials and the need for reimbursement to Medicare.
Key Takeaway
Workers' compensation covers federal employees and select groups for job-related injuries or illnesses. To avoid issues with medical expenses, it's essential that Medicare enrollees or soon-to-be enrollees familiarize themselves with how workers' compensation might impact their Medicare coverage. Proper reporting of workers' compensation agreements can help prevent future claim rejections and reimbursement obligations.
If you'd like to delve deeper into the world of Medicare set-asides, head over to our Medicare hub for valuable resources.
- The Centers for Medicare & Medicaid Services (CMS) monitors the amount received from workers' compensation for injury- or illness-related medical care, especially when the settlement exceeds $25,000.
- For workplace-related injuries or illnesses, workers' compensation should be the primary payer for medical treatment, but Medicare may step in if costs arise before the workers' compensation settlement is secured.
- When a person is already enrolled in Medicare due to age or Social Security Disability Insurance, and the workers' compensation settlement is $25,000 or more, workers' compensation must submit a Total Payment Obligation to the Claimant (TPOC) to CMS.
- If a person is not yet enrolled in Medicare but will be within 30 months of the settlement date, and the workers' compensation settlement is $250,000 or more, workers' compensation must also submit a TPOC to CMS.
- Misusing the funds from a Medicare set-aside arrangement (WCMSA) for unauthorized purposes can lead to claim denials and the need for reimbursement to Medicare.
- A WCMSA is voluntary, but it becomes necessary for settlements exceeding $25,000 or if the person is eligible for Medicare within 30 months and the settlement is $250,000 or more.
