Workers' Compensation and Medicare: Essential Facts to Understand
Working with Medicare and Workers' Compensation: A Comprehensive Guide
Navigating workers' compensation and Medicare can be tricky, but it's essential to stay on top of things to avoid claim denials, reimbursements, and potential penalties.
Workers' compensation serves as insurance for employees who sustain injuries or illnesses directly related to their jobs. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor is in charge of this benefit, which caters to federal employees, their families, and select entities.
Individuals enrolled in Medicare or approaching qualification must understand how their workers' compensation benefits could impact Medicare's medical claim coverage, as this is vital to avoid complications with work-related injury expenses.
How does a workers' comp settlement influence Medicare coverage?
Under Medicare's secondary payer policy, workers' compensation is required to serve as the primary payer for any treatment related to a work-related injury. If urgent medical costs arise before the workers' compensation settlement is received, Medicare might cover the initial costs 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) typically monitors the amount a person receives from workers' compensation for medical care related to their injury or illness. In some cases, Medicare may ask for the creation of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover expenses once the WCMSA funds are exhausted.
Which settlements must be reported to Medicare?
Workers' compensation must submit a Total Payment Obligation to the Claimant (TPOC) to CMS to ensure Medicare covers the appropriate portion of a person's medical expenses if a Medicare-eligible individual is involved, and the settlement includes medical costs.
TPOCs are needed if a person is already enrolled in Medicare based on their age or Social Security Disability Insurance, and the settlement amounts to $25,000 or more. Additionally, TPOCs are necessary if the person isn't yet enrolled in Medicare but will qualify for the program within 30 months of the settlement date, and the settlement amounts to $250,000 or more.
A person must also report to Medicare if they file a liability or no-fault insurance claim.
FAQs
To contact Medicare with questions, dial 800-MEDICARE (800-633-4227, TTY 877-486-2048), or during specific hours, access a live chat on Medicare.gov. For questions regarding the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary, but if a Medicare beneficiary chooses to establish one, their workers' compensation settlement must be over $25,000, or over $250,000 if they're eligible for Medicare within 30 months.
Yes, it's prohibited to misuse the funds in a Medicare set-aside arrangement for purposes other than those designated, as it could lead to claim denials and the need to reimburse Medicare.
"Learn more: Understanding Medicare set-asides## Takeaway**
Workers' compensation is insurance for work-related injuries or illnesses for federal employees and certain groups.
Educating yourself about workers' compensation and how it interacts with Medicare is crucial to prevent issues with medical expenses, especially for those enrolled in or close to qualifying for Medicare.
Ensuring proper reporting of workers' compensation agreements to Medicare is vital to avoid claim denials and reimbursement obligations.
Medicare resources
Explore our Medicare hub for additional resources to help guide you through the complexities of medical insurance.
On top of Medicare and Workers' Compensation, understanding topics such as health-and-wellness, therapies-and-treatments, and nutrition are vital for overall health.
To avoid claim denials and reimbursements due to a workers' comp settlement, learn about the required submission of Total Payment Obligation to the Claimant (TPOC) for settlements worth $25,000 or more for ongoing Medicare enrollees, or $250,000 or more for those impending Medicare eligibility within 30 months.
For those who choose a Medicare set-aside, ensure that the arrangement is not misused; otherwise, you may need to reimburse Medicare for improperly allocated funds.
In addition to our comprehensive guide, see our Medicare hub for further resources on managing medical insurance effectively.
