Medicare and Workers' Compensation Interactions: Essential Guidance
Staying on top of Medicare matters is crucial if you're injured on the job and receiving workers' comp benefits. Failure to report your settlements could lead to claim denials or reimbursements down the line.
Workers' compensation is a safety net for employees who deal with work-related injuries or illnesses. The Office of Workers' Compensation Programs, part of the Department of Labor, administers this insurance for federal workers, their families, and qualifying entities.
If you're already on Medicare or expect to be soon, it's essential to understand how workers' comp could impact Medicare's coverage for your medical bills. This will help prevent disputes over medical costs for work-related injuries.
How does a workers' comp settlement impact Medicare?
Under Medicare's secondary payer policy, workers' comp needs to foot the bill for any treatment related to your work injury before Medicare steps in.
In case immediate medical costs arise prior to you receiving your workers' comp settlement, Medicare may cover the costs initially and start a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To avoid recovery proceedings, the Centers for Medicare & Medicaid Services (CMS) usually monitors the amount you receive from workers' comp for your injury-related medical expenses. In some situations, Medicare might require a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover expenses after the WCMSA funds have run out.
What settlements need to be reported to Medicare?
The employers or insurance carriers handling your workers' comp must submit a total payment obligation to the claimant (TPOC) to CMS to guarantee that Medicare covers the proper portion of your medical expenses. This includes the total amount owed to you or on your behalf.
If you're already on Medicare because of your age or Social Security Disability Insurance, and the settlement is $25,000 or more, submit the TPOC. Bear in mind that TPOCs are also necessary if you're not on Medicare yet but will be 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 should report it to Medicare as well.
Frequently Asked Questions
Questions about Medicare can be addressed by phone at 800-MEDICARE (800-633-4227). For TTY users, dial 877-486-2048, or use the live chat through Medicare.gov at specific hours. If you have concerns about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary, but if your workers' comp settlement exceeds $25,000, or $250,000 if you're eligible for Medicare within 30 months, you should consider establishing one.
Using the funds in a Medicare set-aside arrangement for purposes other than those designated can lead to claim denials and reimbursements to Medicare.
Learn More: What to knowledge about Medicare set-aside arrangements
Takeaway
Workers' compensation insurance lends a helping hand to job-related injuries or illnesses for certain groups such as federal workers. It's vital that those registered for Medicare, or who will be soon, educate themselves on how workers' compensation may impact their Medicare coverage to avoid future problems with medical costs.
Always inform Medicare about your workers' comp agreements to prevent potential claim rejections and reimbursement obligations in the future.
Medicare resources
Check out our Medicare hub for additional resources to help navigate the complex world of medical insurance.
- Workers' compensation insurance is essential for federal employees facing work-related injuries or illnesses.
- The Office of Workers' Compensation Programs, part of the Department of Labor, manages this insurance for eligible individuals.
- Medicare needs to be aware of workers' comp settlements to prevent future claim denials or reimbursement obligations.
- If your workers' comp settlement exceeds $25,000, or $250,000 if you're eligible for Medicare within 30 months, you should consider establishing a Medicare set-aside arrangement.
- Misuse of funds in a Medicare set-aside arrangement can lead to claim denials and reimbursements to Medicare.
- To avoid such scenarios, it's crucial to understand how workers' comp can impact Medicare's coverage for medical bills related to work injuries.
