Medicare and Workers' Compensation: Crucial Facts You Should Understand
It is essential for individuals receiving workers' compensation benefits due to job-related injuries or illnesses to inform Medicare about these arrangements to avoid claim denials or reimbursement obligations. Without proper notification, Medicare may consider immediate medical expenses and subsequently seek reimbursement.
Workers' compensation serves as insurance for federal employees and certain other groups who suffer work-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor manages this benefit, which also applies to the families of federal employees and specific entities.
Individuals enrolled in Medicare or nearing eligibility should understand the impact of workers' compensation on their Medicare coverage. This understanding helps prevent complications with medical costs for work-related injuries or illnesses.
Workers' Compensation Settlements and Medicare
Under Medicare's secondary payer policy, workers' compensation must be the primary provider for any treatment related to a work-related injury. However, if immediate medical expenses arise before an individual receives their workers' compensation settlement, Medicare may cover these expenses initially, initiating a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To prevent a recovery process, the Centers for Medicare & Medicaid Services (CMS) typically monitors the amount a person receives from workers' compensation for their injury or illness-related medical care. In some cases, Medicare may ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover the care after the funds in the WCMSA have been exhausted.
Settlements Requiring Reporting 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 person is already enrolled in Medicare based on their age or Social Security Disability Insurance, and the settlement is $25,000 or more, TPOC submission is necessary.
Additionally, if the person is not yet enrolled in Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more, a TPOC submission is required. Additionally, individuals must report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
For questions related to Medicare, individuals can contact Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is also available on Medicare.gov. For questions about the Medicare recovery process, individuals can contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary. However, if a Medicare beneficiary wishes to set one up, their workers' compensation settlement must be over $25,000, or over $250,000 if the individual becomes eligible for Medicare within 30 months. It is prohibited to use the money in a Medicare set-aside arrangement for purposes other than those designated, as doing so may result in claim denials and the need to reimburse Medicare.
Workers' compensation settlement management by Medicare beneficiaries involves several steps, including understanding Medicare Set Asides (MSAs), reporting requirements, compliance, and professional assistance to ensure compliance with reporting requirements and effective MSA management. By adhering to these steps and staying informed about evolving regulations, Medicare beneficiaries can manage their workers' compensation settlements effectively, avoiding potential claim denials and reimbursement obligations.
For more resources to help guide individuals through the complex world of medical insurance, visit the Medicare hub.
- In the event of a workers' compensation settlement for job-related injuries or illnesses, it is important to understand that Medicare considers workers' compensation as the primary payer for any related treatments, as stipulated by Medicare's secondary payer policy.
- If an individual is enrolled in or nearing eligibility for Medicare, and their workers' compensation settlement is $25,000 or more, a Total Payment Obligation to the Claimant (TPOC) must be submitted to the Centers for Medicare & Medicaid Services (CMS).
- To avoid complications with medical costs and potential reimbursement obligations, it is vital for Medicare beneficiaries to manage their workers' compensation settlements, including understanding Medicare Set Asides (MSAs), reporting requirements, compliance, and seeking professional assistance when necessary.
