Medicare and Workers' Compensation: Essential Facts Explained
Workin' with work comp while on Medicare ain't no simple task, no sir. Forget to let Medicare know about a work comp situation, and you're likely lookin' at claim denials and gotta pay 'em back.
Work comp insurance covers those who've been hurt or got sick doin' their job, and it's managed by the Office of Workers' Compensation Programs under the Dept. of Labor. This covers federal employees, their families, and more.
If you're already on Medicare or bout to qualify, it's essential to grasp how work comp might affect Medicare's coverage of medical bills for job-related injuries or illnesses. Helps prevent problems with medical costs later.
So, How's a Work Comp Settlement Affect Medicare?
Under Medicare's secondary-payer policy, work comp needs to be the main payer for any work-related medical care you receive. But, if somethin's wrong and Medicare pays first, they'll start a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To avoid that mess, the Centers for Medicare & Medicaid Services (CMS) keeps tabs on the amount you get from work comp for Medical care related to your injury or illness.
In some cases, Medicare might ask for a work comp Medicare set-aside arrangement (WCMSA) for these funds. Medicare pays for medical care only after all the money in the WCMSA has been spent.
Settlements to Report to Medicare
Work comp needs to send a total payment obligation to the claimant (TPOC) to CMS. This shows the overall amount of work comp owed to you or on your behalf. You gotta submit a TPOC if you're already on Medicare or qualify for Medicare within 30 months of the settlement date, and the settlement is $25,000 or more. TPOCs are also necessary if you're not on Medicare yet, but will be within 30 months and your settlement is $250,000 or more. Plus, you gotta report any liability or no-fault insurance claims, too.
Frequently Asked Questions
Got questions? Call 800-MEDICARE (800-633-4227, TTY 877-486-2048) weekdays or hop on Medicare.gov during certain hours for a live chat. Need help with the Medicare recovery process? Contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A WCMSA's voluntary, but you gotta have a work comp settlement over $25,000 or $250,000, if you're gonna set one up. And remember, never misuse the money in a WCMSA 'cause that might lead to claim denials and Payin' back Medicare.
It's straight-up prohibited to use WCMSA funds for any other purpose. Ignorin' that rule can cause claim denials and the need to repay Medicare.
- If you receive a work comp settlement exceeding $25,000 and are already on Medicare or will qualify within 30 months, you're required to inform Medicare by submitting a Total Payment Obligation to the Claimant (TPOC).
- A Work comp Medicare set-aside arrangement (WCMSA) can be used to manage Medicare's recovery process in cases where Medicare might normally pay for medical care related to a job-related injury or illness.
- In the healthcare system, it's crucial to understand that if work comp is the primary payer, but Medicare accidentally pays first, a recovery process managed by the Benefits Coordination & Recovery Center (BCRC) will ensue.
- Work comp settlements fall under the category of 'therapies and treatments,' and it's essential to handle them properly to avoid unnecessary costs and potential claim denials, especially for those on Medicare.
