Medicare and Workers' Compensation Interactions: Key Points to Understand
Rewritten Article:
Navigating the interplay between Medicare and workers' compensation is vital for those who've suffered job-related injuries or illnesses. Buckle up as we walk you through the ins and outs to prevent claim denials and unnecessary reimbursements.
Workers' compensation serves as insurance for personnel encountering injuries or diseases directly linked to their occupation. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor handles this benefit, catering to federal employees, their families, and eligible entities.
People currently enrolled in Medicare or soon-to-be enrollees must grasp how their workers' compensation benefits impact Medicare's coverage of work-related medical claims. This understanding is crucial to prevent complications with healthcare expenses.
The Impact of a Workers' Compensation Settlement on Medicare
Under Medicare's secondary payer policy, workers' compensation is the primary payer for treatment related to a work-related injury. However, if urgent medical expenses arise before the individual receives their workers' compensation settlement, Medicare might pay first and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
In such a scenario, the Centers for Medicare & Medicaid Services (CMS) strives to monitor the amount a person receives from workers' compensation for their injury or illness-related medical care. In certain instances, Medicare may request the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover the care once all the money in the WCMSA has been depleted.
What Settlements Require Reporting to Medicare?
Workers' compensation must submit a total payment obligation to the claimant (TPOC) to CMS to ensure Medicare covers the appropriate portion of a person's medical expenses. This represents the total amount of workers' compensation owed to the person or on their behalf.
It's necessary to submit a TPOC if a person is already enrolled in Medicare based on age or based on receiving Social Security Disability Insurance, and the settlement is $25,000 or more.
TPOCs are also required if the person is not currently 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.
Apart from workers' comp, a person must report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
You can reach out to Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During specific 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, but if a Medicare beneficiary wishes to set one up, their workers' compensation settlement must be over $25,000. Alternatively, it must be over $250,000 if they are eligible for Medicare within 30 months.
Yes. Misusing the money in a Medicare set-aside arrangement like a WCMSA for purposes other than the one for which it is designated is prohibited. Misusing the funds can lead to claim denials and reimbursement obligations.
In Conclusion
Workers' compensation is insurance for job-related injuries or illnesses for federal employees and certain groups.
For those enrolled in Medicare or heading towards eligibility, educating yourself on how workers' compensation may impact your Medicare coverage is crucial to avoid issues with medical expenses.
Remember to inform Medicare about workers' compensation agreements to avoid future claim rejections and reimbursement obligations.
Medicare Resources
For additional resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
- In navigating the relationship between Medicare and workers' compensation, it's essential to understand that workers' compensation is the primary payer for work-related medical claims, but Medicare may pay temporarily if urgent expenses arise before the settlement.
- If a workers' compensation settlement is $25,000 or more for an individual already enrolled in Medicare, or $250,000 or more for someone becoming eligible within 30 months, a Total Payment Obligation to the Claimant (TPOC) must be submitted to Medicare to ensure proper coverage of medical expenses.
- Apart from workers' comp, liability or no-fault insurance claims must also be reported to Medicare.
- Misusing funds in a Medicare set-aside arrangement like a WCMSA for purposes other than intended can lead to claim denials and reimbursement obligations and is therefore strongly discouraged.
