Understanding the Interplay between Workers' Compensation and Medicare: Essential Info
Fresh Take:
Navigating the intersection of workers' compensation and Medicare is crucial for folks who've been injured on the job and are covered by Medicare or soon will be. Overlooking this aspect can lead to denied claims and reimbursement obligations.
Workers' Comp and Medicare: What's the Deal?
Workers' compensation provides financial aid for job-related injuries or sickness to federal employees and select others. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor handles this benefit.
If you're already enrolled in Medicare or will shortly qualify, it's essential to understand how your workers' comp might impact Medicare's coverage of your injury-related medical claims. This is key to avoiding trouble with medical expenses stemming from work accidents.
Workers' Comp Settlements and Medicare: The Lowdown
Thanks to Medicare's secondary payer policy, workers' comp should cover any treatment you receive for a work injury before Medicare stepping in. However, immediate medical expenses may force Medicare to foot the bill temporarily, with a recovery process managed by the Benefits Coordination & Recovery Center (BCRC) later. To avoid the recovery process, Medicare tends to monitor the amount you receive from workers' comp for your injury-related medical care.
In some situations, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare won't cover the care until the WCMSA funds are depleted.
The Settlements You Need to Report to Medicare
Workers' comp is required to submit a total payment obligation to the claimant (TPOC) to Medicare to ensure Medicare covers the appropriate portion of your medical expenses. This represents the total sum owed to you or on your behalf.
You'll need to submit a TPOC if you're already in Medicare based on your age or Social Security Disability Insurance (SSDI) eligibility, and the settlement is $25,000 or more.
TPOCs are also necessary if you're not currently in Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more.
Note that if you file a liability or no-fault insurance claim, as well, it needs to be reported to Medicare.
Frequently Asked Questions
To ask Medicare any question, reach them at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During specific hours, you can also chat with them on Medicare.gov. For queries regarding the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A WCMSA is voluntary, but if you want to set one up, your workers' comp settlement must be over $25,000 or $250,000 if you're eligible for Medicare within 30 months. Mishandling the funds in a WCMSA can lead to denied claims and reimbursement obligations.
A WCMSA is a financial arrangement that sets aside funds for future medical expenses resulting from a work injury for Medicare beneficiaries. The WCMSA should be reported to Medicare during the settlement process to comply with MSP laws and guidelines. Starting July 17, 2025, CMS will no longer accept or review proposals with a zero-dollar allocation for WCMSAs.
Key Components of a WCMSA:
Establishment: A WCMSA is established during the settlement of a workers' compensation claim when the claimant is a Medicare beneficiary or expected to become one within 30 months.
Separate Funds: The funds allocated for the WCMSA must be kept in a separate, interest-bearing account to protect the claimant's future medical benefits.
Reporting to Medicare: The WCMSA must be reported to Medicare to ensure compliance with the MSP laws.
- To avoid potential complications with health-and-wellness expenses related to work injuries, it's essential for folks covered by Medicare or soon to be, to understand the intersection between workers' compensation and Medicare.
- Medicare's science-based policies dictate that workers' compensation should cover any injury-related medical treatments before Medicare steps in, but immediate expenses may cause Medicare to pay first, leading to a recovery process managed by the Benefits Coordination & Recovery Center (BCRC) later.
- In certain circumstances, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for the funds designated for future injury-related medical treatments.
- Key components of a WCMSA include the establishment of the arrangement during the workers' compensation settlement, the separation of funds in an interest-bearing account, and reporting the arrangement to Medicare to ensure compliance with Medicare's healthsystems rules and guidelines.
