Medicare and Workers' Compensation: Essential Information You Need to Understand
Pulling the Curtain Back on Workers' Compensation and Medicare
Navigating the intersection of workers' compensation and Medicare is crucial for those who've suffered job-related injuries. Failure to follow the right steps can lead to claim denials and reimbursement obligations down the road.
Workers' compensation serves as a safety net for federal employees and others who experience injuries or illnesses in the workplace. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor handles these benefits, covering federal employees, their families, and other eligible entities.
For those already enrolled in Medicare or approaching eligibility, understanding how workers' compensation affects Medicare coverage is paramount. This understanding helps avoid complications with medical expenses related to work injuries.
** settlements impact on Medicare
Under Medicare's secondary payer policy, workers' compensation is responsible for covering any treatment linked to a work-related injury. However, in instances where immediate medical expenses arise before the person receives their workers' compensation settlement, Medicare may pay first and initiate a recovery process. This process is managed by the Benefits Coordination & Recovery Center (BCRC).
To avoid such a recovery process, the Centers for Medicare & Medicaid Services (CMS) recommends monitoring the amount a person receives from workers' compensation for injury medical care. In some cases, Medicare may ask for the establishment of a workers' compensation Medicare Set-Aside Arrangement (WCMSA), covering care only after all the funds in the WCMSA have been utilized.
To Report or Not to Report
Workers' compensation is required to submit a Total Payment Obligation to the Claimant (TPOC) to CMS if the person is already enrolled in Medicare based on age or Social Security Disability Insurance, and the settlement is $25,000 or more. TPOCs are also necessary if the person is not enrolled in Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more.
In addition to workers' comp, a person must report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
Questions can be directed to Medicare via phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During specific hours, a live chat is also available on Medicare.gov. For questions about the Medicare recovery process, reach out to the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary, but one must be established if the person's workers' compensation settlement exceeds $25,000 or $250,000 within 30 months if they are eligible for Medicare. Misusing funds designated for a Medicare set-aside can lead to claim denials and reimbursement obligations.
"Learn more: What to know about Medicare Set-Asides"
Takeaway
Workers' compensation is crucial for job-related injuries or illnesses for federal employees and others. Educating yourself on how workers' compensation may impact Medicare coverage is essential, especially for those enrolled in or approaching Medicare eligibility.
Reporting workers' compensation agreements is crucial to avoid future claim rejections and reimbursement obligations.
Resources
Visit our Medicare hub for additional resources to help you navigate the complex world of medical insurance.
- Medicare's secondary payer policy dictates that workers' compensation should cover any treatment linked to a work-related injury, but Medicare may pay first if immediate expenses arise before the workers' compensation settlement.
- A Medicare set-aside is necessary if the workers' compensation settlement exceeds $25,000 or $250,000 within 30 months, especially for those who are already enrolled in Medicare or will qualify within 30 months of the settlement date.
- Reporting workers' compensation agreements is crucial to avoid future claim rejections and reimbursement obligations, as well as complying with the Total Payment Obligation to the Claimant (TPOC) reporting requirements.
