Understanding Workers' Compensation and Medicare Interactions: Essential Information
Navigating the world of Medicare benefits and workers' compensation isn't always a walk in the park. As a federal employee or part of a eligible group, having workers' comp insurance for job-related injuries or illnesses is essential.
But if you're on Medicare or about to be, it's crucial to understand how your workers' comp might impact your Medicare coverage. This knowledge can save you from unnecessary medical cost complications following an injury at work.
Workers' comp settlements and Medicare - What's the deal?
Under Medicare's secondary payer policy, workers' comp should always be the primary payer for any work-related injury treatment. In situations where immediate medical expenses arise before you receive your workers' comp settlement, Medicare might pay first and then initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To prevent a recovery process and ensure Medicare covers only the appropriate portion of your medical expenses, the Centers for Medicare & Medicaid Services (CMS) generally monitors the amount you receive from workers' comp for your injury-related medical care. In some cases, Medicare may ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover the care after all the money in the WCMSA has been exhausted.
Reporting the settlement to Medicare - what's required?
Workers' comp must submit a Total Payment Obligation to the Claimant (TPOC) to CMS to ensure Medicare covers the right portion of your medical expenses. Submitting a TPOC is necessary if you're already enrolled in Medicare based on your age or receiving Social Security Disability Insurance, and the settlement is $25,000 or more.
If you're 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, TPOCs are also necessary. Apart from workers' comp, you must also report if you file a liability or no-fault insurance claim.
Frequently asked questions
You can contact Medicare with any question by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is also available on Medicare.gov. If you have questions about the Medicare recovery process, you can contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary. However, if you want to set one up, your workers' comp settlement must be over $25,000. Alternatively, it must be over $250,000 if you're eligible for Medicare within 30 months.
Yes, it's prohibited to use the money in a Medicare set-aside arrangement for any purpose other than the one for which it's designated. Misusing the money can lead to claim denials and having to reimburse Medicare.
Takeaway
Educating yourself on how workers' compensation may affect your Medicare coverage is essential. To avoid future claim rejections and reimbursement obligations, it's crucial to inform Medicare about your workers' comp agreements.
For more information about medical insurance, check out our Medicare hub. Stay informed and protected with the latest updates and comply with Medicare Secondary Payer protocols.
- Under Medicare's secondary payer policy, workers' comp should always be the primary payer for any work-related injury treatment.
- In some cases, Medicare may ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for workers' comp funds.
- Workers' comp must submit a Total Payment Obligation to the Claimant (TPOC) to CMS if the settlement is $25,000 or more and the person is already enrolled in Medicare or receiving Social Security Disability Insurance.
- Misusing the money in a Medicare set-aside arrangement is prohibited and can lead to claim denials and having to reimburse Medicare.
