Understanding the Interplay between Workers' Compensation and Medicare: Crucial Facts to Bear in Mind
Importance of Informing Medicare about Workers' Compensation Arrangements
ensuring claim denials and reimbursement obligations are avoided.
Employees injured or ill due to their jobs may qualify for workers' compensation benefits, which are managed by the Office of Workers' Compensation Programs (OWCP) under the Department of Labor. This insurance covers federal employees, their families, and certain other entities.
When an employee receiving Medicare or soon to qualify for it sustains a job-related injury, understanding the impact of workers' compensation benefits on Medicare's coverage of medical claims is crucial. This understanding helps prevent complications with medical costs related to work injuries.
Understanding Workers' Compensation Settlements and Medicare
Under Medicare's secondary payer policy, workers' compensation must cover any medical treatment for work-related injuries before Medicare steps in. However, if immediate expenses arise before the employee receives their workers' compensation settlement, Medicare may cover the initial costs and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To prevent such recovery processes, the Centers for Medicare & Medicaid Services (CMS) commonly monitors the amount an employee receives from workers' compensation for their injury-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's funds are exhausted.
Required Reporting of Workers' Compensation Settlements
Workers' compensation is responsible for submitting a total payment obligation to the claimant (TPOC) to CMS to ensure Medicare covers the appropriate portion of a person's medical expenses. This submission is necessary for all Medicare beneficiaries, regardless of their enrollment status, if the settlement is $25,000 or more or if they will qualify for Medicare within 30 months and the settlement amount is $250,000 or more.
In addition to workers' comp, a person must report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
Individuals with questions can contact Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or on live chat during certain hours at Medicare.gov. For questions about 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 wants to set one up, their workers' compensation settlement must be over $25,000 or over $250,000 if they are eligible for Medicare within 30 months. It is prohibited to use the money in a Medicare set-aside arrangement for any purpose other than its designated use, as misuse can lead to claim denials and reimbursement obligations.
Key Takeaways
- Careful management of workers' compensation settlements by Medicare beneficiaries avoids claim denials and reimbursement obligations.
- It is essential to inform Medicare about workers' compensation agreements to prevent future claim rejections and reimbursement obligations.
- Enrolled or soon-to-be enrolled Medicare beneficiaries must understand the potential impact of workers' compensation on their Medicare coverage.
- Reporting is required if the workers' compensation settlement is $25,000 or more or if the person will qualify for Medicare within 30 months and the settlement amount is $250,000 or more.
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- Medicare beneficiaries who receive workers' compensation settlements should manage these funds carefully to avoid claim denials and reimbursement obligations.
- A Medicare set-aside arrangement is voluntary, but if interested, the settlement must be over $25,000 or over $250,000 if the person is eligible for Medicare within 30 months.
- Misuse of funds in a Medicare set-aside arrangement can lead to claim denials and reimbursement obligations, so it's crucial to adhere to its designated use.
- According to Medicare regulations, reporting is required when the workers' compensation settlement is $25,000 or more or if the person will qualify for Medicare within 30 months and the settlement amount is $250,000 or more.
