Navigating Workers' Compensation and Medicare: Essential Facts to Understand
Navigating the intersection of workers' compensation and Medicare is essential to avoid financial headaches. Ignoring this connection could lead to claim denials and the need to reimburse Medicare.
Workers' compensation provides benefits to employees who've suffered job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP), part of the Department of Labor, oversees this insurance program for federal employees, their families, and more.
As a Medicare beneficiary, it's vital to grasp how workers' compensation may influence Medicare's coverage of medical expenses associated with workplace injuries. This understanding helps prevent complications with medical bills arising from work-related accidents.
How does a workers' comp settlement affect Medicare?
Since Medicare is a secondary payer, workers' compensation must cover all treatment costs for work-related injuries first. However, if emergency medical expenses come up before the workers' compensation settlement, Medicare may pay initially and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To avoid a recovery process, the Centers for Medicare & Medicaid Services (CMS) may monitor the amount a person receives from workers' compensation for injury-related medical care. In some cases, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will then only cover care once the WCMSA is depleted.
What settlements need to be reported to Medicare?
Workers' compensation must submit a Total Payment Obligation to the Claimant (TPOC) to CMS when the settlement exceeds certain thresholds to ensure Medicare covers the appropriate portion of a person's medical expenses. This reporting is crucial for people already enrolled in Medicare, as well as those who will qualify within 30 months of the settlement date and receive social security disability insurance. The TPOC reporting applies when the settlement is $25,000 or more for current Medicare beneficiaries, or $250,000 or more for those with impending Medicare eligibility within 30 months.
Additionally, if the person files a liability or no-fault insurance claim, they must also report to Medicare.
Frequently asked questions
If you have questions, you can get in touch with Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or through the live chat available on Medicare.gov. For questions regarding the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary, but if a Medicare beneficiary wishes to set one up, their workers' compensation settlement must be over $25,000, or over $250,000 if they will be eligible for Medicare within 30 months. It's important to remember that using money from a Medicare set-aside arrangement for anything other than its intended purpose is prohibited. Violating this rule can result in claim denials and reimbursement obligations to Medicare.
Takeaway
Workers' compensation offers crucial assistance for job-related injuries or illnesses. For those enrolled in Medicare or approaching eligibility, it's essential to understand how workers' compensation may impact their Medicare coverage. Informing Medicare about workers' compensation agreements helps prevent future claim rejections and reimbursement obligations.
- Recipients of workers' compensation should understand that Medicare acts as a secondary payer, requiring workers' compensation to cover all treatment costs for work-related injuries before Medicare takes effect.
- When a workers' compensation settlement exceeds certain thresholds, it must be reported to Medicare through the Total Payment Obligation to the Claimant (TPOC) to ensure that Medicare covers the suitable portion of the person's medical expenses.
- In some cases, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for funds related to injury-related medical care. Medicare will then only cover care once the WCMSA is depleted.
- If a person files a liability or no-fault insurance claim along with a workers' compensation claim, they must also report this to Medicare.
- To get clarification or additional information, one can contact Medicare by phone at 800-MEDICARE or through the live chat available on Medicare.gov, or contact the Benefits Coordination & Recovery Center (BCRC) at 855-798-2627 for questions regarding the Medicare recovery process.
