Navigating worker's compensation and Medicare: Key insights to understand
Rewritten Article:
Navigating the waters of workers' compensation and Medicare can be tricky. Failure to notify Medicare about a workers' comp arrangement could lead to claim denials and potential reimbursement obligations.
Workers' compensation serves as insurance for individuals who suffer injuries or illnesses directly due to their jobs. The Office of Workers' Compensation Programs (OWCP), under the purview of the Department of Labor, manages this benefit for federal employees, their families, and certain other entities.
If you're already enrolled in Medicare or will soon be eligible, understanding how workers' compensation might impact Medicare's coverage of your medical claims is essential to avoid complications with medical costs resulting from work-related injuries.
How does a workers' comp settlement impact Medicare?
Under Medicare's secondary payer policy, workers' compensation must be the primary payer for any treatment related to a work-related injury. However, if immediate expenses arise before you get your workers' comp settlement, Medicare may pay first and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To avoid this recovery process, and to monitor the funds related to your injury treatment, the Centers for Medicare & Medicaid Services (CMS) generally keeps tabs on the amount you receive from workers' compensation.
In some cases, Medicare may ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA). Medicare will only cover the care after all the money in the WCMSA has been used up.
What settlements have to 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 claimant's medical expenses. This represents the total amount of workers' compensation owed to the person or on their behalf.
You need to submit a TPOC if you're already enrolled in Medicare based on age or receiving Social Security Disability Insurance, and the settlement is $25,000 or more. TPOCs are also necessary if you're not currently 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. Additionally, if you file a liability or no-fault insurance claim, you must also report it to Medicare.
Frequently asked questions
You can contact Medicare with any questions 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 you have questions about the Medicare recovery process, you can contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary. However, if you want to set up one, your workers' compensation settlement must be over $25,000. Alternatively, it must be over $250,000 if you're eligible for Medicare within 30 months. It is prohibited to use the money in a Medicare set-aside arrangement for any purpose other than the intended use. Misusing the funds can lead to claim denials and reimbursement responsibilities.
"Learn more: What to know about Medicare set-aside
Takeaway
Workers' compensation is a crucial insurance for work-related injuries or illnesses for federal employees and certain other groups. Educating yourself on how workers' compensation may impact Medicare coverage is important to ensure medical costs are covered correctly and prevent complications. Properly reporting workers' compensation arrangements to Medicare will help avoid future claim rejections and potential reimbursement obligations.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
- Failure to inform Medicare about a workers' compensation arrangement could lead to claim denials and potential reimbursement obligations, especially in cases of work-related injuries.
- The Office of Workers' Compensation Programs (OWCP), under the Department of Labor, manages workers' compensation benefits for federal employees, their families, and specific entities.
- Under Medicare's secondary payer policy, Medicare must be covered only after workers' compensation has paid for any treatment related to a work-related injury.
- Medicare may ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) to cover care after all the money in the WCMSA has been used.
- Workers' compensation must submit a total payment obligation to the claimant (TPOC) to Medicare for settlements of $25,000 or more if already enrolled in Medicare or eligible within 30 months, or $250,000 or more if not currently enrolled.
- It is prohibited to use the money in a Medicare set-aside arrangement for any purpose other than the intended use, and misusing the funds can result in claim denials and reimbursement responsibilities.
