Medicare and Workers' Compensation: Key Facts to Understand
Revamped Guide:
Navigating the world of workers' compensation and Medicare is a must for those who've suffered job-related injuries or illnesses. Failure to handle this correctly can lead to claim denials and reimbursement issues.
Workers' compensation offers insurance to federal employees and certain groups for work-related ailments. The Office of Workers' Compensation Programs (OWCP) within the Department of Labor manages this benefit.
If you're enrolled in Medicare or soon will be, understanding how workers' compensation might affect your medical coverage is vital. This knowledge can save you from costly complications down the line.
Here's the Lowdown:
How does a workers' comp settlement interact with Medicare? Under Medicare's secondary payer policy, workers' compensation needs to be the primary payer for any treatment related to a work-related injury. If immediate expenses surge before you receive your workers' comp settlement, Medicare may cover first, initiating a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To steer clear of a recovery process, the Centers for Medicare & Medicaid Services (CMS) often monitor the amount you receive from workers' compensation for your injury- or illness-related medical care. In some instances, Medicare might ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only pay for your care after all the money in the WCMSA has been spent.
What Settlements Need to be Reported to Medicare?
If you're already on Medicare due to age or receiving Social Security Disability Insurance, and the settlement is $25,000 or more, you'll need to share the Total Payment Obligation to the Claimant (TPOC) with CMS.
If you're not on Medicare yet but will sign up within 30 months of the settlement date, and the settlement amount is $250,000 or more, you'll also need to report the TPOC.
In addition to workers' comp, you should also report to Medicare if you file a liability or no-fault insurance claim.
Frequently Asked Questions
You can reach out to Medicare by phone at 800-MEDICARE, or during certain hours, via live chat on Medicare.gov. If you have questions about the Medicare recovery process, contact the BCRC at 855-798-2627.
A Medicare set-aside is voluntary, but if you want to establish one, your workers' compensation settlement should be over $25,000 (or over $250,000 if you're eligible for Medicare within 30 months).
It's prohibited to use the money in a Medicare set-aside arrangement for any purpose besides the one it's designated for. Misusing the funds could lead to claim denials or reimbursement obligations.
Pro tips:
- Learn More: Get more insights about Medicare set-asides.
- Keep it Seamless: Follow the above steps to ensure smooth coverage and avoid denials or reimbursement obligations related to workers' compensation settlements.
Resources:For further guidance on navigating the complex world of medical insurance, explore our Medicare hub.
- Recipients of workers' compensation benefits from the Office of Workers' Compensation Programs (OWCP) should be aware of how it might impact their 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.
- If immediate expenses occur before receiving workers' compensation settlement, Medicare may cover them initially, initiating a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
- Medicare might ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for injury- or illness-related funds from the settlement.
- Reporting is required to Medicare if a settlement, whether from workers' comp, liability, or no-fault insurance, equals or exceeds $25,000 and the recipient is already on Medicare, or will be within 30 months of the settlement date.
- A Medicare set-aside is a voluntary arrangement, but it's recommended for settlements over $25,000 (or over $250,000 if the recipient is eligible for Medicare within 30 months) to ensure smooth coverage and avoid reimbursement obligations.
- Misuse of funds designated for a Medicare set-aside arrangement could lead to claim denials or reimbursement obligations.
