Medicare and Workers' Compensation: Essential Information for Understanding the Intersections
Shedding Light on Workers' Compensation and Medicare:
Navigating the intersection of workers' compensation and Medicare is crucial to avoid claim denials and reimbursement obligations.
Workers' compensation serves as insurance for employees who suffer job-related injuries or illnesses, overseen by the Office of Workers' Compensation Programs (OWCP) under the Department of Labor.
If you're enrolled in Medicare or expect to be soon, understanding the impact of workers' compensation on your Medicare benefits is essential to manage medical costs for work-related injuries.
Workers' Compensation and Medicare: A Closer Look
Under Medicare's secondary payer policy, workers' compensation needs to take the lead in covering any treatment for work-related injuries. Nevertheless, if immediate medical expenses arise before the workers' compensation settlement, Medicare might pay first and initiate the Benefits Coordination & Recovery Center's (BCRC) recovery process. To prevent this, the Centers for Medicare & Medicaid Services (CMS) closely monitors workers' compensation settlements.
In specific cases, Medicare may enforce the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Only after all the money in the WCMSA has been exhausted will Medicare cover the remaining care.
What Settlements Require Reporting to Medicare?
Workers' compensation must submit the Total Payment Obligation to the Claimant (TPOC) to CMS to ensure Medicare covers the right portion of medical expenses. This represents the total compensation owed to the individual.
Reporting a TPOC is compulsory if the individual is already enrolled in Medicare, based on age or Social Security Disability Insurance, and the settlement exceeds $25,000. TPOCs are also necessary if the individual has yet to enroll in Medicare but will within 30 months of the settlement date, and the settlement value surpasses $250,000. Furthermore, a person must report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
- To contact Medicare, dial 800-MEDICARE (800-633-4227), TTY 877-486-2048. During specific hours, a live chat is accessible on Medicare.gov. For questions about the Medicare recovery process, call the BCRC at 855-798-2627 (TTY 855-797-2627).
- Setting up a Medicare set-aside is voluntary, but it's essential if the workers' compensation settlement surpasses $25,000 or $250,000 within 30 months if the individual is eligible for Medicare.
- Misusing funds from a Medicare set-aside arrangement can result in claim denials and reimbursement demands from Medicare.
Takeaway
Familiarize yourself with workers' compensation and its influence on Medicare to prevent problems with medical expenses. Be sure to report workers' compensation agreements to avoid future claim rejections and reimbursement obligations.
For additional resources on medical insurance, visit our Medicare hub.
- The Office of Workers' Compensation Programs (OWCP) oversees workers' compensation, which serves as insurance for employees who sustain job-related injuries or illnesses.
- Workers' compensation needs to cover any treatment for work-related injuries before Medicare does, as per Medicare's secondary payer policy.
- Centers for Medicare & Medicaid Services (CMS) closely monitors workers' compensation settlements, and in certain cases, Medicare may enforce the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA).
- Workers' compensation must submit the Total Payment Obligation to the Claimant (TPOC) to CMS if the individual is already enrolled in Medicare or will within 30 months of the settlement date, and the settlement exceeds specified thresholds.
- When a TPOC needs to be reported, it is mandatory for workers' compensation to submit it to CMS to ensure Medicare covers the correct portion of medical expenses.
- Misusing funds from a Medicare set-aside arrangement can lead to claim denials and reimbursement demands from Medicare.
