Medicare and workers' compensation: Crucial insights to be aware of
Workers' Compensation Claims and Medicare: Essential Information for Beneficiaries
Understanding the relationship between workers' compensation and Medicare is crucial for individuals who have experienced work-related injuries or illnesses. Failing to notify Medicare about a workers' compensation arrangement can result in claim denials and the need to reimburse Medicare.
Workers' compensation functions as insurance for employees who suffer injuries or illnesses directly related to their jobs. The Office of Workers' Compensation Programs (OWCP), part of the Department of Labor, oversees this benefit for federal employees, their families, and eligible entities.
Individuals enrolled in Medicare or preparing to enroll should grasp how their workers' compensation benefits may intersect with Medicare's coverage of their medical expenses. This knowledge can help prevent complications with medical costs linked to work-related injuries.
The Impact of Workers' Compensation Settlements on Medicare
Medicare's secondary payer policy dictates that workers' compensation must cover any treatment related to a work-related injury before Medicare steps in. However, if a person incurs immediate medical expenses before 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 Centers for Medicare & Medicaid Services (CMS) normally monitor the amount a person receives from workers' compensation for their injury or illness-related medical care. In certain cases, Medicare may require a workers' compensation Medicare set-aside arrangement (WCMSA) to manage these funds. Medicare will only cover the care after all the money in the WCMSA has been spent.
Settlements Requiring Reporting to Medicare
Workers' compensation is required to submit a total payment obligation to the claimant (TPOC) to CMS to ensure Medicare covers the appropriate portion of a person's medical expenses. This represents the total amount of workers' compensation owed to the person or on their behalf.
Submitting a TPOC is mandatory if the person is already enrolled in Medicare based on their age or based on receiving Social Security Disability Insurance, and the settlement exceeds $25,000. Additionally, reporting is necessary if the person is not currently enrolled in Medicare but will qualify for the program within 30 months of the settlement date, and the settlement amount is $250,000 or more. Moreover, a person must report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
For questions regarding Medicare, individuals can contact Medicare directly by phone at 800-MEDICARE (800-633-4227) or TTY 877-486-2048. During certain hours, a live chat is also available on Medicare.gov. For questions 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 wishes to set one up, their workers' compensation settlement must be over $25,000 if they are currently enrolled in Medicare, or over $250,000 if they are eligible for Medicare within 30 months. It is also important to note that it is prohibited to misuse the money in a Medicare set-aside arrangement (WCMSA); doing so can lead to claim denials and the need to reimburse Medicare.
For more comprehensive resources on Medicare, visit our Medicare hub.
- To manage expenses related to work-related injuries when workers' compensation settlements exceed specific thresholds, Medicare may require a Medicare set-aside arrangement (WCMSA).
- For individuals already enrolled in Medicare or those who will qualify within 30 months of a settlement date, reporting the total payment obligation to the claimant (TPOC) to Medicare is mandatory if the settlement exceeds $25,000 or $250,000, respectively.
- Medicare provides resources to answer questions about their program and the recovery process; beneficiaries can contact Medicare's customer service at 800-MEDICARE or the Benefits Coordination & Recovery Center at 855-798-2627.
- Misusing funds intended for a Medicare set-aside arrangement (WCMSA) can result in claim denials and the need to reimburse Medicare, which makes it crucial to adhere to the proper use of these funds.
In addition to the topics mentioned above, healthcare systems, health-and-wellness, fitness-and-exercise, nutrition, therapies-and-treatments, and science are relevant in discussions about overall individual health and wellbeing, separate from workers' compensation.
