Medicare and Workers' Compensation: Key Points to Understand
Importance of Notifying Medicare Regarding Workers' Compensation Arrangements
Individuals receiving Medicare benefits must be cautious about their workers' compensation arrangements. Failing to notify Medicare about such arrangements may lead to claim denials and the requirement to reimburse Medicare.
Workers' compensation serves as insurance for employees who experience job-related injuries or illnesses. This insurance is administered by the Office of Workers' Compensation Programs (OWCP) within the Department of Labor, and it extends to federal employees, their families, and specific other entities.
People currently enrolled in Medicare or soon to qualify need to understand how their workers' compensation benefits might interact with Medicare's coverage of their medical claims, particularly when it comes to work-related injuries. This understanding is essential to avoid complications with medical expenses.
How Workers' Compensation Impacts Medicare Coverage
Under Medicare's secondary payer policy, workers' compensation is expected to be the primary payer for any treatment related to a work-related injury. However, if immediate medical expenses arise before an individual receives their workers' compensation settlement, Medicare may cover these expenses initially and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To avoid such recovery processes, the Centers for Medicare & Medicaid Services (CMS) typically monitors the amount an individual receives from workers' compensation for injury- or illness-related medical care. In some instances, Medicare may request 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 depleted.
Reportable Workers' Compensation Settlements
Workers' compensation insurers 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 submission is necessary for those who are already enrolled in Medicare based on their age or Social Security Disability Insurance, and for whom the settlement is $25,000 or more.
If a person is not currently enrolled in Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more, TPOCs are also required. In addition to workers' comp, a person must report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
To contact Medicare with any questions, dial 800-MEDICARE (800-633-4227, TTY 877-486-2048). During specific hours, live chat is available on the Medicare.gov website. For questions about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary, but if the beneficiary chooses to set one up, their workers' compensation settlement must exceed $25,000 or $250,000 within 30 months, depending on their Medicare eligibility. Misusing the funds in a Medicare set-aside can lead to claim denials and the need to reimburse Medicare.
For further information, explore the Medicare hub for resources designed to navigate the complexities of medical insurance.
Key Takeaway
Workers' compensation insures job-related injuries or illnesses for federal employees and certain other groups.
To prevent issues with medical expenses for those enrolled in Medicare or soon to be eligible, it is crucial to understand how workers' compensation might impact Medicare coverage. It is also essential to inform Medicare about workers' compensation agreements to avoid future claim rejections and reimbursement obligations.
- Failing to notify Medicare about workers' compensation arrangements may result in claim denials and the obligation to reimburse Medicare.
- Under Medicare's secondary payer policy, workers' compensation is expected to be the primary payer for any treatment related to work-related injuries, but Medicare may cover initial expenses and initiate a recovery process if needed.
- Workers' compensation insurers must submit a Total Payment Obligation to the Claimant (TPOC) to Medicare when a settlement is $25,000 or more for individuals already enrolled in Medicare, or $250,000 or more for those who will qualify within 30 months.
- Medicare may monitor the amount an individual receives from workers' compensation for injury- or illness-related medical care and may request the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds.
- Medicare offers resources through the Medicare hub to help navigate the complexities of medical insurance, including answering questions about workers' compensation and the Medicare recovery process.
