Medicare and Workers' Compensation Interactions: Key Points to Understand
Navigating Workers' Compensation and Medicare: What You Need to Know
Don't put yourself in a bind by failing to notify Medicare about your workers' compensation arrangements. Neglecting to do so can lead to claim denials and the obligation to reimburse Medicare.
Workers' compensation serves as insurance coverage for employees who've suffered injuries or illnesses directly linked to their jobs. Overseen by the Office of Workers' Compensation Programs (OWCP), this benefit applies to federal employees, their families, and select other entities.
For those already enrolled in or soon to qualify for Medicare, it's vital to comprehend how workers' compensation might influence Medicare's coverage of medical claims related to workplace injuries or illnesses. Clarifying these factors prevents hassles with medical expenses incurred at work.
How does a workers' comp settlement impact Medicare?
Medicare operates under the "secondary payer" policy, meaning workers' compensation should cover the initial treatment for a work-related injury. However, if urgent medical expenses arise prior to the recipient receiving their workers' compensation settlement, Medicare might cover the initial costs and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
Consequently, the Centers for Medicare & Medicaid Services (CMS) generally aims to monitor the amount received from workers' compensation for injury- or illness-related medical care to avoid a recovery process. In some cases, Medicare might request the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover the care once the funds in the WCMSA are depleted.
What settlements demand reporting to Medicare?
Workers' compensation must submit a Total Payment Obligation to the Claimant (TPOC) to CMS to guarantee that Medicare covers the appropriate percentage of a person's medical expenses. This represents the total amount owed to the person or their representatives.
Submitting a TPOC is mandatory if the person is already enrolled in Medicare based on their age or on receiving Social Security Disability Insurance (SSDI), and the settlement is $25,000 or more.
TPOCs are also necessary if the person isn't enrolled in Medicare yet but will qualify for the program 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
You can query Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or through a live chat on Medicare.gov during available hours. For questions about the Medicare recovery process, call the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is optional. However, if a Medicare beneficiary wishes to establish one, their workers' compensation settlement must be over $25,000. Alternatively, it must be over $250,000 if they are eligible for Medicare within 30 months.
Yes, it is prohibited to misuse the funds in a Medicare set-aside arrangement, such as a WCMSA, for any purpose other than its intended purpose. Misuse can trigger claim denials and an obligation to reimburse Medicare.
"Learn more: What to know about Medicare set-aside arrangements"
A Helpful Guide
Workers' compensation is insurance coverage for job-related injuries or illnesses for federal employees and select other groups.
By educating yourself on how workers' compensation might impact your Medicare coverage, you can prevent complications with medical expenses.
It's essential to inform Medicare about your workers' compensation agreements to avoid future claim rejections and reimbursement obligations.
Additional Resources
For more resources to help navigate the complex landscape of medical insurance, explore our Medicare hub.
- "[1] CMS Fact Sheet: Section 111 Reporting Requirements for Workers' Compensation MSA Settlements"
- "[2] CMS Workers' Compensation Medicare Set-Aside Arrangements (WCMSA) Informational Bulletin"
- "[3] CMS Workers' Compensation Medicare Set-Aside Arrangements (WCMSA) Reference Guide"
- "[4] CMS Section 111 Reporting Web Interface Guidebook for Workers' Compensation Medicare Set-Aside Arrangements (WCMSA) Settlements"
- Failing to inform Medicare about your workers' compensation arrangements can lead to claim denials and an obligation to reimburse Medicare.
- For federal employees who have suffered injuries or illnesses related to their jobs, workers' compensation acts as insurance coverage overseen by the Office of Workers' Compensation Programs (OWCP).
- In the event a workers' compensation recipient requires urgent medical care prior to receiving their settlement, Medicare might cover the initial costs and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
- The Centers for Medicare & Medicaid Services (CMS) tends to monitor the amount received from workers' compensation for injury- or illness-related medical care to prevent a recovery process. In certain cases, Medicare might require the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds.
