Medicare and Workers' Compensation: Essential Facts Explored
Workers' Compensation and Medicare: A Crucial Connection for Claimants
It is imperative for individuals receiving workers' compensation to notify Medicare about their arrangement. Failure to do so may result in claim denials and reimbursement obligations.
Workers' compensation functions as insurance for employees who have sustained job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP), a component of the Department of Labor, oversees this benefit, which extends to federal employees, their families, and select other entities.
Those currently enrolled in Medicare or approaching eligibility need to comprehend how their workers' compensation benefits might influence Medicare's coverage of their medical claims. This understanding is vital to prevent complications with medical costs related to work injuries or illnesses.
How Does a Workers' Compensation Settlement Affect Medicare?
Medicare adheres to the secondary payer policy, which dictates that workers' compensation should serve as the primary payer for any treatment related to a work-related injury. In situations where immediate medical expenses arise prior to the worker receiving their compensation settlement, Medicare might initially pay these costs and institute a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To prevent a recovery process and secure proper coverage, the Centers for Medicare & Medicaid Services (CMS) typically monitors the amount a person receives from workers' compensation for their injury-related medical care. In some instances, Medicare may request the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover the care following the depletion of the WCMSA funds.
Which Settlements Require Reporting to Medicare?
Workers' compensation is obligated to 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 complete amount of workers' compensation owed to the person or on their behalf.
Such reporting is mandatory if the person is already enrolled in Medicare based on age or Social Security Disability Insurance, and the settlement exceeds $25,000. Additionally, if the person is not currently enrolled in Medicare but will qualify within 30 months of the settlement date, and the settlement amount totals $250,000 or more, a TPOC is necessary.
Moreover, people must report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
Questions concerning Medicare can be addressed by contacting Medicare directly at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is also 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 establish one, their workers' compensation settlement must exceed $25,000, or $250,000 if they are eligible for Medicare within 30 months. Misusing the funds in a Medicare set-aside arrangement can lead to claim denials and reimbursement obligations.
Key Takeaway
Recipients of workers' compensation must collaborate with Medicare to avoid future claim rejections and reimbursement obligations. This necessitates careful planning and ongoing administration, including the establishment and management of a Workers' Compensation Medicare Set-Aside (WCMSA), as well as adherence to reporting requirements and proper billing procedures.
- Workers' compensation functions as the primary payer for treatments related to work-related injuries, following the secondary payer policy set by Medicare.
- The Centers for Medicare & Medicaid Services (CMS) requires reporting of a total payment obligation to the claimant (TPOC) from workers' compensation if the settlement exceeds $25,000 for those already enrolled in Medicare or those who will qualify in the subsequent 30 months.
- A Medicare set-aside arrangement (WCMSA) can be established voluntarily for injuries with settlements exceeding these thresholds, but misusing the funds in the WCMSA may result in claim denials and reimbursement obligations.
- Nutrition, health-and-wellness, therapies-and-treatments, and healthsystems fall outside the scope of this discussion about Workers' Compensation and Medicare, but it's crucial to note that individuals receiving workers' compensation benefits may require these resources for recovery and rehabilitation, which may also warrant consideration under the Medicare secondary payer policy.
