Comprehending the Intersection between Workers' Compensation and Medicare: Key Insights
Navigating the intricacies of Medicare and workers' compensation is a must for anyone enrolled or planning to enroll in Medicare. Failing to do so could lead to claim denials and the need for costly reimbursements.
Workers' compensation offers financial assistance to individuals who’ve suffered job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor handles this benefit, available to federal employees, their families, and specific other entities.
When it comes to Medicare, understanding how workers' compensation benefits may affect your coverage is crucial to avoid complications with your medical expenses.
How does a workers' comp settlement affect Medicare?
Under Medicare's Secondary Payer policy, workers' compensation must foot the bill for any work-related injury treatment. However, if immediate medical expenses arise before an individual receives their workers' compensation settlement, Medicare might pay first. In such cases, the Benefits Coordination & Recovery Center (BCRC) initiates a recovery process.
To prevent a recovery process and to manage the amount paid for injury or illness-related medical care, the Centers for Medicare & Medicaid Services (CMS) often aims to monitor the funds from workers' compensation settlements. In certain cases, Medicare might ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA). Medicare will only cover care after all the money in the WCMSA has been spent.
What settlements have to be reported to Medicare?
Workers' compensation should provide CMS with a Total Payment Obligation to the Claimant (TPOC) to ensure Medicare covers the appropriate portion of a person's medical expenses. This applies if a person is already on Medicare or will soon qualify for it based on age or Social Security Disability Insurance, and the settlement is $25,000 or more.
Additionally, if the person isn’t enrolled in Medicare but will be eligible within 30 months of the settlement date, and the settlement amount is $250,000 or more, a TPOC is needed. Settlements from liability or no-fault insurance claims should also be reported to Medicare.
FAQs
You can contact Medicare with questions through their toll-free hotline (800-MEDICARE) or online chat sessions on Medicare.gov, available during specific hours. For Medicare recovery concerns, 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 exceed $25,000 or $250,000 if they will be eligible for Medicare within 30 months. Misusing the funds in a Medicare set-aside arrangement can lead to claims denials and the need to reimburse Medicare.
Takeaway
Workers' compensation provides insurance for job-related injuries or illnesses for federal employees and other groups. Educating yourself on how workers' compensation may impact your Medicare coverage is vital to avoid issues with medical expenses and claim rejections. Reporting workers' compensation agreements to Medicare can prevent future claim denials and reimbursement obligations.
For more resources on navigating the complex world of medical insurance, visit our Medicare hub.
- The Centers for Medicare & Medicaid Services (CMS) often aims to monitor the funds from workers' compensation settlements to manage the amount paid for injury or illness-related medical care.
- Workers' compensation should provide CMS with a Total Payment Obligation to the Claimant (TPOC) if a person is already on Medicare or will soon qualify for it based on age or Social Security Disability Insurance, and the settlement is $25,000 or more.
- A Medicare set-aside is voluntary, but if a Medicare beneficiary wants to set one up, their workers' compensation settlement must exceed $25,000 or $250,000 if they will be eligible for Medicare within 30 months.
