Understanding the Interplay between Workers' Compensation and Medicare: Crucial Facts to Keep in Mind
Revised Base Article:
Navigating Medicare with a workers' compensation arrangement is a must. Failing to notify Medicare about this can lead to claim denials and the need to reimburse the insurance program.
Workers' compensation serves as insurance for employees who suffer occupational injuries or illnesses. The Office of Workers' Compensation Programs (OWCP), under the Department of Labor, is in charge of this benefit, which applies to federal employees, their families, and specific other entities.
People already enrolled in Medicare or soon to join its ranks need to grasp how their workers' compensation benefits might impact Medicare's coverage of their medical claims related to workplace accidents. This is vital to prevent complications with medical bills stemming from jobsite injuries.
How does a work comp settlement affect Medicare?
Under Medicare's secondary payer policy, workers' compensation needs to serve as the primary payer for any treatments linked to a work-related injury.
However, if immediate medical expenses arise before an individual receives their work comp settlement, Medicare may pay first and then initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To avoid this recovery process, the Centers for Medicare & Medicaid Services (CMS) typically aims to track the amount a person receives from workers' compensation for their injury or illness-related medical care.
In some instances, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare won't cover care until the WCMSA funds have been exhausted.
What settlements require reporting to Medicare?
Workers' compensation must 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 total amount of workers' compensation owed to the person or on their behalf.
Reporting a TPOC is necessary if a person is already enrolled in Medicare based on their age or based on receiving Social Security Disability Insurance, and the settlement is $25,000 or more.
TPOCs are also necessary if the person is not yet enrolled in Medicare but will qualify for the program within 30 months of the settlement date, and the settlement amount is $250,000 or more.
Apart from workers' comp, a person must report to Medicare if they file a liability or no-fault insurance claim.
FAQs
A person can contact Medicare with questions via phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is also available on Medicare.gov. If a person has questions about the Medicare recovery process, they can contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary. However, if a Medicare beneficiary wishes to establish one, their workers' compensation settlement must exceed $25,000. Alternatively, it must be over $250,000 if they are eligible for Medicare within 30 months.
Yes. Misusing funds in a Medicare set-aside arrangement (e.g., WCMSA) for purposes other than those designated can result in claim denials and the need to reimburse Medicare.
"Learn more: What to know about Medicare set-asides"
Takeaway:
Workers' compensation is insurance for job-related injuries or illnesses for federal employees and certain other groups.
It is essential that those enrolled in Medicare or soon to be eligible educate themselves on how workers' compensation might affect their Medicare coverage to avoid issues with medical expenses.
Proper reporting of workers' compensation agreements can help avoid future claim rejections and reimbursement obligations.
Medicare resources
For more resources to help navigate the complex world of medical insurance, visit our Medicare hub.
- Uncategorized: It's important to understand that misusing funds in a Medicare Set-aside arrangement (WCMSA) for purposes other than those designated can result in claim denials and the need to reimburse Medicare.
- Healthsystems: Navigating Medicare with a workers' compensation arrangement is crucial, especially for federal employees and specific other entities who are beneficiaries of the Office of Workers' Compensation Programs (OWCP).
- Health-and-wellness: People already enrolled in Medicare or soon to join its ranks need to understand how their workers' compensation benefits might impact Medicare's coverage of their medical claims related to workplace accidents, which is vital to prevent complications with medical bills stemming from jobsite injuries.
- Therapies-and-treatments: A Medicare set-aside arrangement (WCMSA) might be required by Medicare in some instances, as Medicare won't cover care until the WCMSA funds have been exhausted.
- Finance and Business: Workers' compensation must submit a total payment obligation to the claimant (TPOC) to CMS, and it is necessary to report this TPOC if a person is already enrolled in Medicare based on their age or based on receiving Social Security Disability Insurance, and the settlement is $25,000 or more, or if the person is not yet enrolled in Medicare but will qualify for the program within 30 months of the settlement date, and the settlement amount is $250,000 or more.
