Understanding Workers' Compensation and Medicare Interactions: Essential Facts to Remember
Navigating the intersection of workers' compensation and Medicare is all-important for federal employees, among others, to avoid costly issues with medical bills.
Workers' compensation, managed by the Office of Workers' Compensation Programs (OWCP) under the Department of Labor, covers job-related injuries and illnesses for eligible individuals. When these people are concurrently enrolled in or expect to join Medicare, understanding the impact of workers' compensation on Medicare coverage is vital.
What's the deal with workers' comp settlements and Medicare?
By Medicare's secondary payer policy, workers' compensation should take the lead in covering work-related injury treatments. If instant medical expenses arise prior to the workers' compensation settlement, Medicare might jump in and begin the recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To evade this recovery process and ensure uninterrupted Medicare coverage, the Centers for Medicare & Medicaid Services (CMS) generally monitors the workers' compensation settlement amount allocated for work-related injury treatments.
In some situations, Medicare might request the creation of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only kick in to pay for treatments once the amount within the WCMSA has been exhausted.
Which settlements must be reported to Medicare?
When a person enrolled in Medicare due to their age or Social Security Disability Insurance eligibility receives a workers' compensation settlement of $25,000 or more, they are required to submit a total payment obligation to the claimant (TPOC) to CMS.
Additionally, if the person will qualify for Medicare within 30 months of the settlement date and the settlement amount is $250,000 or more, the TPOC must also be submitted. Besides workers' comp, a person needs to notify Medicare if they file a liability or no-fault insurance claim.
All your burning questions about Medicare, answered!
For any questions or concerns, reach out to Medicare via phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or use the live chat offered on Medicare.gov during designated hours. For queries regarding the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A WCMSA is voluntary. Nevertheless, if a Medicare beneficiary wishes to establish one, their workers' compensation settlement must exceed $25,000 or $250,000 if they become eligible for Medicare within 30 months. It's strictly forbidden to misuse money within a WCMSA for purposes other than those designated, as it may result in claim rejections and reimbursement obligations for the beneficiary.
Learn more: What to know about Medicare set-asides
Insurance for job-related injuries or illnesses, workers' compensation, is crucial for federal employees and certain other groups to prevent financial headaches caused by medical expenses related to their employment.
Educating yourself on how workers' compensation affects Medicare coverage is key to maintaining medical costs in check for work-related injuries or illnesses. Notifying Medicare about workers' compensation arrangements is fundamental to decrease the risk of claim denials and reimbursement obligations.
Medicare resources
Visit our Medicare hub for more resources to help guide you through the complex world of medical insurance.
- Workers' compensation, managed by the Office of Workers' Compensation Programs (OWCP), is crucial for federal employees and others to cover job-related injuries and illnesses.
- When enrolled in Medicare, understanding the impact of workers' compensation on Medicare coverage is vital, especially when dealing with work-related injury treatments.
- Under Medicare's secondary payer policy, workers' compensation should precede Medicare in covering work-related injury treatments.
- If a person enrolled in Medicare receives a workers' compensation settlement of $25,000 or more or qualifies for Medicare within 30 months and the settlement amount is $250,000 or more, they are required to submit a Total Payment Obligation to the Claimant (TPOC) to the Centers for Medicare & Medicaid Services (CMS).
- A Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) is voluntary but may be needed if a settlement amount exceeds $25,000 or $250,000 within 30 months of Medicare eligibility.
- In navigating the intersection of workers' compensation and Medicare, it's essential to familiarize yourself with the various risks, therapies, and treatments involved, as well as the process of submitting relevant information to CMS to avoid costly issues with medical bills.
