Medicare and workers' compensation interplay: essential insights
Let's Talk Workers' Comp, Medicare, and Your Settlement
In the world of work and health insurance, it's crucial to know how workers' compensation plays with Medicare. That's right, knowing the ins and outs could save you from claim denials and money reimbursements.
Workers' comp is the insurance for workplace injuries and illnesses. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor handles it for federal employees, their families, and more.
Now, not many folks know this, but employees with Medicare coverage or about to join should understand how workers' comp benefits might impact their medical claim coverage. You wouldn't want medical costs for work-related injuries causing a headache.
So, how does a workers' comp settlement affect Medicare?
Under Medicare's secondary payer policy, workers' comp should cover any treatment for a work-related injury before Medicare jumps in. But, if immediate medical expenses arise before the workers' comp settlement, Medicare might foot the bill first, launching a recovery process handled by the Benefits Coordination & Recovery Center (BCRC).
To avoid this recovery process, the Centers for Medicare & Medicaid Services (CMS) monitor the amount a person receives from workers' comp for their injury or illness-related medical care. On occasion, Medicare might ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover care once the WCMSA funds are depleted.
What settlements need to be reported to Medicare?
For Medicare to cover the right portion of a person's medical expenses, workers' comp must submit a Total Payment Obligation to the Claimant (TPOC) to CMS. This represents the total amount owed to an individual from workers' comp.
You need to submit a TPOC if you're already enrolled in Medicare or will soon be on Medicare based on age or Social Security Disability Insurance, and the settlement is $25,000 or more. Or if you're not yet on Medicare but will be within 30 months of the settlement date, and the settlement amount is $250,000 or more.
Remember, it's not just workers' comp. You must also report if you file a liability or no-fault insurance claim to Medicare.
Got questions?
Just ring up 800-MEDICARE (800-633-4227, TTY 877-486-2048), or during certain hours, you can chat live on Medicare.gov. If you're curious about Medicare's recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
What's a WCMSA?
A Medicare set-aside is voluntary, but for one to be set up, the workers' comp settlement must be over $25,000 or $250,000 if you're eligible for Medicare within 30 months.
Warning: All WCMSA funds must be used only for their designated purpose, or claim denials and having to reimburse Medicare could be on the horizon.
"Learn more: What to know about Medicare set-asides## The Lowdown
Workers' compensation is insurance for job-related injuries or illnesses, mainly for federal employees and some other groups.
It's important for individuals receiving Medicare or soon to be eligible to understand how workers' comp might impact their Medicare coverage to sidestep issues with medical expenses.
Remember, reporting workers' comp agreements to Medicare is vital to avoid future claim rejections and reimbursement obligations.
Medicare Resources
Visit our Medicare hub for more resources to help you navigate the complex world of medical insurance.
- Workers' compensation, a type of insurance for job-related injuries and illnesses, is essential for federal employees and other groups to understand, as it may impact their Medicare coverage.
- If you are already enrolled in Medicare or will soon be due to age or Social Security Disability Insurance, and your workers' comp settlement is $25,000 or more, you must submit a Total Payment Obligation to the Claimant (TPOC) to Medicare.
- If you are not yet on Medicare but will be within 30 months of the settlement date, and the settlement amount is $250,000 or more, you should also submit a TPOC.
- Medicare sets up a workers' compensation Medicare set-aside arrangement (WCMSA) if it monitors the amount received from workers' comp for injury or illness-related medical care, ensuring Medicare covers care only once the WCMSA funds are depleted.
- A WCMSA is a voluntary arrangement, but it must be established if the workers' comp settlement is over $25,000 or $250,000 if you're eligible for Medicare within 30 months.
- Misuse of WCMSA funds may lead to claim denials and reimbursements to Medicare, so all funds should be used only for their designated purpose.
