Understanding Workers' Compensation and Medicare Interactions: Crucial Information Details
Critical Information for Workers' Compensation Beneficiaries Enrolled in Medicare
To ensure the accurate processing of claims, it is crucial for individuals receiving workers' compensation benefits, particularly those enrolled in Medicare, to report these arrangements to the Centers for Medicare & Medicaid Services (CMS). Failure to report may result in claim denials and the need to reimburse Medicare.
Workers' compensation is insurance designed to cover injuries or illnesses directly related to employment. The Office of Workers' Compensation Programs (OWCP) within the Department of Labor administers this benefit for federal employees, their families, and certain other groups.
Understanding how workers' compensation may impact Medicare coverage is essential to avoid complications with medical costs related to work-related injuries.
Impact of Workers' Compensation Settlements on Medicare
Under Medicare's secondary payer policy, workers' compensation must cover any treatment for work-related injuries before Medicare steps in. If immediate medical expenses arise prior to the recipient receiving their 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 CMS generally monitors the amount a person receives from workers' compensation for injury or illness-related medical care. In some cases, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medical care will only be covered once the WCMSA funds have been exhausted.
Reporting Workers' Compensation Settlements to Medicare
Workers' compensation settlements must be reported to CMS when the Total Payment Obligation to the Claimant (TPOC) is $25,000 or more and either:
- The recipient is already enrolled in Medicare based on age or Social Security Disability Insurance, or
- The recipient will qualify for Medicare within 30 months of the settlement date, and the settlement amount is $250,000 or more.
In addition to workers' comp, a person must report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
For more information or questions, Medicare can be contacted by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048), or through live chat on Medicare.gov during certain hours. For inquiries about 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 will be eligible for Medicare within 30 months. It is prohibited to use the money in a Medicare set-aside arrangement for any purpose other than the designated purpose. Misuse may lead to claim denials and reimbursement obligations.
For more resources to guide you through the complex world of medical insurance, visit the Medicare hub.
- Workers' compensation insurance settlements must be reported to the Centers for Medicare & Medicaid Services (CMS) if the Total Payment Obligation to the Claimant (TPOC) is $25,000 or more, especially for individuals who are already enrolled in Medicare or will qualify within 30 months.
- Medicare's secondary payer policy requires workers' compensation to cover any treatment for work-related injuries before Medicare steps in, and some cases may require a workers' compensation Medicare set-aside arrangement (WCMSA) to manage the funds for these treatments.
- Understanding both workers' compensation and Medicare, along with therapies-and-treatments, health-and-wellness, nutrition, and science gained through these systems, is essential to secure accurate claim processing and avoid complications with medical costs related to work-related injuries.
- Uncategorized expenses related to a Medicare set-aside arrangement must not be used for purposes other than the designated purpose, as misuse may lead to claim denials and reimbursement obligations.
