Understanding Interplay Between Workers' Compensation and Medicare: Essential Information
Notifying Medicare about a workers' compensation agreement is a must, else you risk claim denials and having to reimburse Medicare.
Workers' compensation serves as insurance for employees who've suffered job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP), falling under the Department of Labor, oversees this benefit for federal employees, their families, and select other entities.
Those currently on Medicare or approaching eligibility need to grasp how workers' compensation might impact Medicare's coverage of medical claims related to work injuries. Understanding these dynamics can help prevent complications with medical costs.
Workers' Comp Settlement and Medicare
Medicare adheres to a Secondary Payer Policy, meaning workers' compensation must pay for work-related injury treatment first. However, if immediate medical expenses crop up before a settlement, Medicare may cover the costs initially and instigate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). In such cases, the CMS aims to monitor the amount a person receives from workers' comp for injury-related medical care. This is to avoid the recovery process and potential complications.
In some instances, Medicare might ask for a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only pay for care once the WCMSA funds are exhausted.
Settlements Worth Reporting to Medicare
Workers' compensation should submit a total payment obligation to the claimant (TPOC) to CMS. This represents the total amount of workers' comp owed to the person or on their behalf. This is required if:
- The person is enrolled in Medicare based on their age or disability and the settlement is $25,000 or more.
- The person will qualify for Medicare within 30 months of the settlement date, and the settlement amount is $250,000 or more.
Apart from workers' comp, a person must also report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
To get in touch with Medicare, dial 800-MEDICARE (800-633-4227, TTY 877-486-2048). During specific hours, a live chat is available on Medicare.gov. If you have questions about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside arrangement, though optional, must exceed $25,000 for enrolled Medicare beneficiaries or $250,000 if Medicare eligibility is expected within 30 months. Misusing funds in a Medicare set-aside arrangement is forbidden, as it can lead to claim denials and reimbursement obligations.
- When a settlement is equal to or above $25,000 for people already on Medicare or those approaching Medicare eligibility due to age or disability, it should be reported to the Centers for Medicare & Medicaid Services (CMS).
- If a person will be eligible for Medicare within 30 months of the settlement date and the settlement amount is $250,000 or more, it must also be reported to CMS.
- Workers' compensation must adhere to Medicare's Secondary Payer Policy, meaning it should cover work-related injury treatment before Medicare covers any costs.
- In cases where immediate medical expenses emerge before a settlement, and Medicare covers the costs initially, it will initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
- Medicare may ask for a workers' compensation Medicare set-aside arrangement (WCMSA) for injury-related funds to prevent complications with the recovery process.
- CBD, a compound from the cannabis plant, is an uncontrolled substance under Medicare, and its inclusion in a workers' compensation settlement might impact Medicare's coverage of medical-related conditions.
- Fitness and exercise, nutrition, science, health-and-wellness, and other similar factors play crucial roles in maintaining good health and can help minimize risks associated with work-related injuries.
