Understanding Intersection Between Workers' Compensation and Medicare Benefits
Article:
Understanding the Interplay Between Workers' Compensation and Medicare
To avoid claim denials and reimbursement obligations, it is crucial for individuals receiving workers' compensation benefits to notify Medicare about their arrangements.
The Office of Workers' Compensation Programs (OWCP), under the Department of Labor, administers workers' compensation for federal employees, their families, and certain other entities. These benefits provide insurance for employees who have sustained injuries or illnesses directly related to their jobs.
It's essential for Medicare enrollees or those soon to qualify to grasp how their workers' compensation benefits could impact Medicare's coverage of medical expenses related to work injuries or illnesses. This understanding can help prevent complications with medical costs.
Workers' comp settlements and Medicare:
Under Medicare's secondary payer policy, workers' compensation should cover any treatment for work-related injuries before Medicare intervenes. However, if immediate medical expenses arise before an individual receives their workers' compensation settlement, Medicare may initially pay for the expenses and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To avoid this recovery process, the Centers for Medicare & Medicaid Services (CMS) often monitor the amount a person receives from workers' compensation for their injury or illness-related medical care. In some cases, Medicare may require a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds, only covering care after the WCMSA has been depleted.
Reporting to Medicare:
Employers are required to submit a Total Payment Obligation to the Claimant (TPOC) to CMS if an individual is already enrolled in Medicare based on age or Social Security Disability Insurance and the settlement is $25,000 or more. Similarly, TPOCs are necessary if the individual will qualify for Medicare within 30 months of the settlement date, and the settlement amount is $250,000 or more.
In addition to workers' comp, individuals must report liability or no-fault insurance claims to Medicare.
Frequently Asked Questions:
For questions related to Medicare, individuals can call 800-MEDICARE or visit Medicare.gov during specified hours to access live chat support. Questions about the Medicare recovery process can be directed to the BCRC at 855-798-2627.
A WCMSA is voluntary but is necessary if the workers' compensation settlement exceeds $25,000 for Medicare beneficiaries, or $250,000 for those expected to qualify for Medicare within 30 months. Misusing WCMSA funds for purposes other than those designated could lead to claim denials and reimbursement obligations.
For more comprehensive resources on Medicare, visit our Medicare hub.
- To ensure proper coverage and prevent complications with medical costs, Medicare enrollees or those soon to qualify should comprehend the potential impact of their workers' compensation benefits on Medicare's coverage of work-related injuries or illnesses.
- In certain cases, the Centers for Medicare & Medicaid Services (CMS) may require a workers' compensation Medicare set-aside arrangement (WCMSA) for funds received from workers' compensation, only covering care after the WCMSA has been depleted.
- Employers are required to report Total Payment Obligation to the Claimant (TPOC) to CMS if an individual is already enrolled in Medicare based on age or Social Security Disability Insurance and the settlement is $25,000 or more, or if the individual will qualify for Medicare within 30 months of the settlement date and the settlement amount is $250,000 or more.
- For individuals seeking resources related to Medicare, health systems, health-and-wellness, therapies-and-treatments, nutrition, and other uncategorized topics, it is recommended to visit the Medicare hub for a comprehensive collection of information.
