Understanding the Interplay between Workers' Compensation and Medicare: Key Points to Consider
Working with Medicare and Workers' Compensation: A Necessary Dance
Navigating the intersection of Medicare and workers' compensation is vital to avoid claim denials and reimbursement obligations. Here's what you need to know:
Understanding Workers' Compensation
Workers' compensation is an insurance policy that protects employees who sustain injuries or illnesses related to their job. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor oversees this benefit, covering federal employees, their families, and various other entities.
The Medicare-Workers' Compensation Relationship
If you're enrolled in Medicare or are soon to be eligible, it's essential to understand the impact of workers' compensation on your Medicare coverage. Workers' compensation serves as the primary payer for work-related injuries or illnesses. In some cases, Medicare may pay initially, only to initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To avoid this recovery process, the Centers for Medicare & Medicaid Services (CMS) often monitor the amount received from workers' compensation for medical care related to the injury or illness. In some instances, Medicare may ask for the creation of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover care once the WCMSA funds have been depleted.
Reporting Settlements to Medicare
If you receive a workers' compensation total payment obligation to the claimant (TPOC) over $25,000, or if you are not currently enrolled in Medicare but will be within 30 months of the settlement date and the settlement amount is $250,000 or more, you'll need to report the settlement to Medicare.
In addition to workers' compensation, you must also report if you file a liability or no-fault insurance claim.
Establishing a WCMSA
A WCMSA is voluntary, but if you want to set one up, your workers' compensation settlement must exceed $25,000 or $250,000 (if you will qualify for Medicare within 30 months). Misusing the funds in a WCMSA for purposes other than their designated purpose can lead to claim denials and reimbursement obligations to Medicare.
Frequently Asked Questions
Questions about Medicare's recovery process can be directed to the BCRC at 855-798-2627 (TTY 855-797-2627). Medicare can be contacted via phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048), or during certain hours, you can access a live chat on Medicare.gov.
Resources
For more comprehensive guidance on navigating the complex world of medical insurance, visit our Medicare hub. For specific information about Medicare Set-Asides, explore our in-depth article titled "What to Know about Medicare Set-Aside."
- Health systems and health-and-wellness providers need to be aware of the interplay between Medicare and workers' compensation, as it can significantly impact claim denials and reimbursement obligations.
- When dealing with Medicare and workers' compensation, it's crucial to understand that workers' compensation is the primary payer for work-related injuries or illnesses, with Medicare potentially initiating a recovery process in specific instances.
- In certain cases, Medicare may require the creation of a workers' compensation Medicare set-aside arrangement (WCMSA) to manage funds related to work-related injuries or illnesses.
- Settlement recipients who receive more than $25,000 from workers' compensation or who will qualify for Medicare within 30 months and receive over $250,000 must report the settlement to Medicare.
- Misusing funds in a WCMSA for purposes other than their designated purpose can lead to claim denials and reimbursement obligations to Medicare.
- Consumers seeking clarification about Medicare's recovery process can contact the Benefits Coordination & Recovery Center (BCRC) at 855-798-2627, or Medicare directly at 800-MEDICARE for phone support, or access a live chat on Medicare.gov during selected hours.
