Medicare and Workers' Compensation: Essential Facts Explored
Got a workers' comp situation? Here's what you gotta know about Medicare.
Don't get caught off guard when it comes to workers' comp and Medicare. Neglecting to notify Medicare about a workers' compensation arrangement could lead to claim denials and being obligated to reimburse the program.
Workers' compensation is a form of insurance that provides benefits to employees who suffer job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP), under the Department of Labor, manages this benefit for federal employees, their families, and certain other entities.
If you're already on Medicare or planning to soon, it's crucial to understand how your workers' comp benefits might impact Medicare's coverage of your medical claims. This helps prevent any confusion or complications with medical costs for work-related injuries or illnesses.
Workers' comp and its impact on Medicare
Under Medicare's secondary payer policy, workers' compensation should cover any treatment related to a work-related injury before Medicare kicks in.
In cases where immediate medical expenses arise prior to receiving your workers' comp settlement, Medicare might step in first, initiating what's known as a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To avoid this, the Centers for Medicare & Medicaid Services (CMS) typically aims to monitor the amount you receive from workers' comp for your injury or illness-related medical care.
In some instances, Medicare may require the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover the care after the WCMSA funds have been depleted.
Reporting your workers' comp settlement to Medicare
When it comes to workers' compensation settlements, Medicare requires a Total Payment Obligation to the Claimant (TPOC) to be submitted to them to ensure they cover the appropriate portion of your medical expenses. You need to submit a TPOC if you're already on Medicare based on your age or based on receiving Social Security Disability Insurance and if the settlement is $25,000 or more. Even if you're not yet on Medicare, you'll need to report if the settlement amount is $250,000 or more and you'll qualify for Medicare within the next 30 months.
If you're filing a liability or no-fault insurance claim as well, you'll also need to report this to Medicare.
Frequently asked questions
Have questions about Medicare and workers' comp? Contact Medicare at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or via live chat on Medicare.gov during certain hours. If you have questions about the Medicare recovery process, reach out to the BCRC at 855-798-2627 (TTY 855-797-2627).
Creating a Medicare set-aside is voluntary, but if you want to set one up, your workers' comp settlement should be over $25,000 (or over $250,000 if you're eligible for Medicare within 30 months).
It's prohibited to use the funds from a Medicare set-aside arrangement for any purpose other than the intended purpose. Misusing the funds can lead to claim denials and having to reimburse Medicare.
Key points to remember
- Workers' compensation is insurance for job-related injuries or illnesses for federal employees and certain other groups.
- It's crucial to inform Medicare about workers' compensation agreements to avoid future claim rejections and reimbursement obligations.
- Proper reporting of workers' compensation settlements to Medicare is essential for maintaining uninterrupted Medicare coverage and for avoiding complications in the recovery process.
For more resources on navigating the intricacies of medical insurance, visit our Medicare hub.
- Workers' comp and health-and-wellness therapies-and-treatments can be connected, as these may be covered under workers' compensation insurance for job-related injuries or illnesses.
- In certain science-oriented healthsystems, Medicare will cover treatments after a workers' compensation Medicare set-aside arrangement (WCMSA) has been depleted, demonstrating the relationship between workers' comp and nutrition-related treatments.
- Uncategorized cases may arise when immediate medical expenses related to work-related injuries or illnesses are paid by Medicare before workers' comp, necessitating the recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
- If you have significant workers' comp settlements (over $25,000 or $250,000, depending on your situation), a Medicare set-aside arrangement (WCMSA) might be required, ensuring that funds are used only for intended health-and-wellness purposes and to prevent complications with Medicare coverage.
