navigating intersections of workers' comp and Medicare: crucial insights
Geared-Up on Workers' Comp and Medicare: A Game Plan for Federal Employees and Beyond
Keeping Medicare updated about your workers' compensation arrangement is a must. Neglecting to do so can lead to claim denials and potential reimbursement obligations.
Workers' compensation insurance is designed to cover injuries or illnesses sustained directly on the job for federal workers, their families, and select other entities. The Office of Workers' Compensation Programs (OWCP) within the Department of Labor manages this benefit.
When it comes to individuals enrolled in Medicare or those approaching eligibility, understanding the interaction between workers' compensation benefits and Medicare coverage is crucial to avoid complications with medical costs for work-related injuries.
Breaking Down Workers' Compensation Settlements and Medicare
Under Medicare's secondary payer policy, workers' compensation must cover medical expenses for work-related injuries before Medicare steps in. In situations where immediate medical expenses arise prior to receiving workers' compensation settlement, Medicare may pay first and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To avoid a recovery process, the Centers for Medicare & Medicaid Services (CMS) aims to monitor the amount a person receives from workers' compensation for their injury-related medical care. Depending on the circumstances, CMS may request the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds.
Settlements to Keep Medicare in the Know
Employers handling workers' compensation must submit a total payment obligation to the claimant (TPOC) to the CMS to ensure Medicare covers appropriate portions of medical expenses. Filing a TPOC is necessary when the individual enrolled in Medicare based on age or Social Security Disability Insurance, and the settlement exceeds $25,000.
Additionally, if the person is not currently enrolled in Medicare but is expected to become eligible within 30 months of the settlement date and the settlement amountis $250,000 or more, a TPOC is required.
In addition to workers' comp, individuals must report to Medicare if they file liability or no-fault insurance claims.
Frequently Answered Questions
You can contact Medicare with any questions by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048), or during certain hours, via a live chat on Medicare.gov. For questions about the Medicare recovery process, call 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, if they are eligible for Medicare within 30 months, it must be over $250,000.
Using the money in a Medicare set-aside arrangement for purposes other than its designated use is prohibited and can lead to claim denials and reimbursement obligations.
"In the Know: Medicare Set-Asides"
Wrap Up
Protecting your Medicare coverage when dealing with worker's compensation claims is vital. Medicare handles worker's compensation settlements through the Medicare Secondary Payer (MSP) statute. An MSA may be necessary when there are anticipated future medical expenses related to the injury, ensuring that Medicare remains the secondary payer.
It's important to report the correct settlement information to Medicare to avoid claim denials and reimbursement obligations. Consulting with legal counsel and MSP compliance experts is recommended.
Medicare Resources
For further guidance on navigating the complexities of medical insurance, visit our Medicare hub.
- Ensuring that Medicare is informed about a workers' compensation settlement is crucial, especially when the settlement exceeds $25,000, to avoid potential claim denials and reimbursement obligations.
- When a person eligible for Medicare based on age or Social Security Disability Insurance receives a workers' compensation settlement, filing a total payment obligation to the claimant (TPOC) with the Centers for Medicare & Medicaid Services (CMS) is necessary.
- To maintain the integrity of a Medicare set-aside arrangement, its funds should only be utilized for the designated purposes related to the injury, as using the money for other purposes is prohibited and can lead to claim denials and reimbursement obligations.
