Navigating the Intersection of Workers' Compensation and Medicare: Crucial Insights
Navigating Medicare when dealing with a workers' compensation arrangement is vital. Failing to notify Medicare might cause claim denials and potential reimbursements.
Workers' compensation serves as insurance for those who've experienced job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor manages this benefit, covering federal employees, their families, and certain other entities.
Individuals already enrolled in Medicare or soon to join need to comprehend how their workers' compensation benefits might influence Medicare's coverage of their medical claims. This understanding is crucial to prevent issues with medical costs for injuries or illnesses arising at work.
How does a workers' comp settlement impact Medicare?
Under Medicare's secondary payer policy, workers' compensation must cover any treatment for work-related injuries. However, if immediate medical expenses occur before the individual receives their workers' compensation settlement, Medicare may pay first and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
The Centers for Medicare & Medicaid Services (CMS) often monitor the amount a person receives from workers' compensation for their injury or illness-related medical care to avoid a recovery process. In some cases, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover the care after all the money in the WCMSA has been spent.
Which settlements must be reported to Medicare?
Workers' compensation must submit a total payment obligation to the claimant (TPOC) to CMS to ensure Medicare covers the appropriate portion of a person's medical expenses. This represents the total amount owed to the person or on their behalf.
Submitting a TPOC is necessary if a person is currently enrolled in Medicare based on their age or based on receiving Social Security Disability Insurance, and the settlement is over $25,000. TPOCs are also essential if the person isn't yet 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.
In addition to workers' comp, a person must report to Medicare if they file a liability or no-fault insurance claim.
Frequently asked questions
A person can contact Medicare with any question by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is also available on Medicare.gov. If a person has questions about the Medicare recovery process, they can contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary. However, if a Medicare beneficiary wants to establish one, their workers' compensation settlement must be over $25,000. Alternatively, it must be over $250,000 if they are eligible for Medicare within 30 months.
Yes. It is prohibited to utilize the money in a Medicare set-aside arrangement (WCMSA) for any purpose other than the one for which it is designated. Misusing the money can lead to claim denials and having to reimburse Medicare.
Takeaway
Workers' compensation is insurance for job-related injuries or illnesses for federal employees and certain other groups.
It is essential that those enrolled in Medicare or soon to be eligible educate themselves on how workers' compensation may affect their Medicare coverage to prevent issues with medical expenses.
It is also crucial to inform Medicare about workers' compensation agreements to avoid future claim rejections and reimbursement obligations.
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
- When dealing with workers' compensation arrangements, understanding the impact on medicare's coverage of health-and-wellness expenses is essential.
- Under the Medicare secondary payer policy, therapies-and-treatments related to work-related injuries must first be covered by workers' compensation, but Medicare may pay initially and then recover the expenses from the Benefits Coordination & Recovery Center (BCRC).
- It's crucial for individuals receiving workers' compensation benefits to report their settlement amount to the Centers for Medicare & Medicaid Services (CMS) by submitting a total payment obligation to the claimant (TPOC). This must be done if the settlement amount is over $25,000, or if the person will qualify for Medicare within 30 months and the settlement is over $250,000.
- Beyond workers' compensation, any liability or no-fault insurance claim settlements also need to be reported to Medicare.
