Medicare considerations and workers' compensation benefits: Essential insights
Vital Info on Workers' Compensation and Medicare
Navigating workers' compensation and Medicare can be tricky, but understanding the connection is crucial to avoid claim denials and reimbursement duties.
Workers' compensation provides support for employees who have suffered job-related injuries or illnesses, jointly managed by the Office of Workers' Compensation Programs (OWCP) under the Department of Labor.
People who already have Medicare or are soon to become eligible need to grasp how their workers' comp benefits might interplay with Medicare's medical coverage for work-related injuries or illnesses to avoid complications with medical expenses.
How a Workers' Comp Settlement Affects Medicare
Under Medicare's secondary payer policy, workers' comp should cover any treatment for work-related injuries before Medicare takes charge.
If immediate medical expenses pop up before the workers' comp settlement lands, Medicare might foot the bill initially but kick off a recovery process handled by the Benefits Coordination & Recovery Center (BCRC).
To bypass the recovery process, the Centers for Medicare & Medicaid Services (CMS) often keeps tabs on the amount a person receives from workers' comp for injury or illness-related medical care. In some cases, Medicare may demand the creation of a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) for these funds. Medicare will only cover the care after the WCMSA cash runs out.
What Settlements Need to Report to Medicare?
Workers' comp entities need to submit the Total Payment Obligation to the Claimant (TPOC) to CMS for Medicare to cover the appropriate portion of the person's medical expenses. TPOCs are essential when a person is already enrolled in Medicare via age or Social Security Disability Insurance, and the settlement is $25,000 or higher.
Similarly, TPOCs are vital if the person is yet to enroll in Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more.
Apart from workers' comp, you must report any liability or no-fault insurance claim to Medicare as well.
Frequently Asked Questions
You can reach Medicare with questions by dialing 800-MEDICARE or 800-633-4227, TTY 877-486-2048 during certain hours. Live chat assistance is also available on Medicare.gov. For queries about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A WCMSA is voluntary, but for settlements exceeding $25,000 or $250,000 (within 30 months of Medicare enrollment eligibility), it's a good idea to set one up. Misusing the funds in a WCMSA can result in claim denials and reimbursement obligations to Medicare.
Bonus Insights
Reporting a workers' compensation settlement to Medicare involves several steps, including Medicare Set-Aside (MSA) allocation, registration, and reporting by Responsible Reporting Entities (RREs). Medicare beneficiaries must also submit annual attestations, keep meticulous records, and notify Medicare when the MSA funds have been used up. Violation of reporting requirements can come with penalties for both RREs and beneficiaries.
For more resources to help navigate the intricate world of medical insurance, visit our Medicare hub.
- People who have Medicare or are about to become eligible should pay attention to the interaction between their workers' comp benefits and Medicare's medical coverage for work-related injuries or illnesses, to steer clear of complications with medical expenses.
- In cases where the Total Payment Obligation to the Claimant (TPOC) from workers' comp entities exceeds $25,000, it's mandatory to report the TPOC to Medicare, especially if the person is already enrolled in Medicare or will qualify within 30 months of the settlement date.
- Medicare covers the appropriate portion of the person's medical expenses only after the Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) funds have been used up.
- Apart from reporting the TPOC, it is essential to inform Medicare about any liability or no-fault insurance claims as well.
