Understanding Workers' Compensation and Medicare Interactions: Crucial Information
Updating Medicare about a Workers' Compensation Agreement: Why it Matters
Navigating the interplay between Workers' Compensation and Medicare is crucial to avoid potential issues with medical expenses and claim denials.
Workers' Compensation is a policy that protects employees who suffer job-related injuries or illnesses. Responsibility for this benefit largely falls upon the Office of Workers' Compensation Programs under the Department of Labor, covering federal employees, their family members, and select other organizations.
For those currently enrolled in Medicare or upcoming beneficiaries, understanding how Workers' Compensation may impact Medicare's coverage of work-related medical claims is vital to prevent complications in medical costs.
Workers' Compensation: Now and Then
Under Medicare's Secondary Payer policy, Workers' Compensation should serve as the primary payer for injuries or illnesses incurred on the job. However, if immediate medical expenses arise before a person receives their Workers' Compensation settlement, Medicare might pay first and initiate a recovery process through the Benefits Coordination & Recovery Center (BCRC).
To avoid this recovery process and its potential drawbacks, the Centers for Medicare & Medicaid Services (CMS) often monitors the total amount a person receives from Workers' Compensation for medical care related to a work-related injury or illness. In certain cases, Medicare might even request the establishment of a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) for these funds. Medicare will cover subsequent care only after all WCMSA funds have been exhausted.
Reporting the Right Way
Workers' Compensation should submit a Total Payment Obligation to Claimant (TPOC) to CMS to ensure that Medicare covers the appropriate proportion of a person's medical expenses. Submitting a TPOC is necessary if the person is enrolled in Medicare based on age or Social Security Disability Insurance, and the settlement is $25,000 or more.
Additionally, TPOCs are essential if the person is not yet enrolled in Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more. Besides Workers' Compensation settlements, a person must also report any liability or no-fault insurance claims to Medicare.
Frequently Asked Questions
A person can contact Medicare about their queries by calling 800-MEDICARE (800-633-4227, TTY 877-486-2048), or during specific hours, a live chat is available on Medicare.gov. Individuals with questions about the Medicare recovery process can contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A WCMSA is optional, but if a Medicare beneficiary wishes to establish one, their Workers' Compensation settlement must exceed $25,000 (or $250,000 if they are eligible for Medicare within 30 months). Misusing WCMSA funds for purposes other than designated items can lead to claim denials and reimbursement obligations.
"Dive Deeper: Understanding Medicare Set-Asides"
Key Takeaway
Workers' Compensation insurance covers job-related injuries or illnesses for federal employees and specific groups. So, it's important for those enrolled in or soon to be enrolled in Medicare to educate themselves concerning the impact of Workers' Compensation on their Medicare coverage to maintain control over medical expenses. Moreover, informing Medicare about Workers' Compensation agreements can prevent future claim rejections and reimbursement obligations.
Medicare Resources
For additional guidance on medical insurance matters, visit our Medicare hub.
- To prevent future claim rejections and reimbursement obligations, it is essential for Medicare beneficiaries to inform Medicare about their Workers' Compensation agreements.
- The Centers for Medicare & Medicaid Services (CMS) monitors the total amount a person receives from Workers' Compensation for medical care related to a work-related injury or illness and may even request the establishment of a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA).
- In cases where a Workers' Compensation settlement exceeds $25,000 (or $250,000 if the person is eligible for Medicare within 30 months), a Total Payment Obligation to Claimant (TPOC) must be submitted to CMS.
- Workers' Compensation insurance covers job-related injuries or illnesses for federal employees and specific groups, and understanding its impact on Medicare's coverage can help maintain control over medical expenses in the realm of health-and-wellness, therapies-and-treatments, and nutrition.
