Understanding the relationship between Workers' Compensation and Medicare: Key Points to Consider
Workin' the Workers' Comp and Medicare System
Navigating the interplay between workers' compensation and Medicare is a must for those who've suffered work-related injuries or illnesses, particularly for federal workers and select entities. Here's a breakdown of what you need to know to prevent disputes over medical costs.
Workers' Comp and Medicare – A Not-So-Straightforward Relationship
When it comes to treatment for job-related injuries, workers' compensation should be the primary payer. However, if immediate medical expenses arise before the workers' compensation settlement, Medicare might step in and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To avoid this, the Centers for Medicare & Medicaid Services (CMS) keeps tabs on the funds received from workers' compensation for injury-related medical care. In certain cases, Medicare may ask for the creation of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds, covering care only after the WCMSA funds are depleted.
What Settlements Dent Medicare's Wallet?
In order for Medicare to cover the correct portion of a person's medical expenses, the Total Payment Obligation to the Claimant (TPOC) must be submitted to CMS. This is necessary for individuals currently enrolled in Medicare based on their age or Social Security Disability Insurance, as well as those who will qualify for Medicare within 30 months of the settlement date if the settlement is $250,000 or more. Additionally, if the settlement is $25,000 or more, it should be reported if the person is already enrolled in Medicare. Likewise, if the person is not enrolled in Medicare but will soon be eligible, the settlement must be reported if it's $250,000 or more. Moreover, individuals need to report liability or no-fault insurance claims to Medicare.
FAQs
Have questions? Dial 800-MEDICARE, TTY 877-486-2048, or chat with Medicare on Medicare.gov during certain hours. If you're curious about the Medicare recovery process, contact the BCRC at 855-798-2627, TTY 855-797-2627.
Clarification Corner
- A WCMSA is optional but required if the workers' compensation settlement is over $25,000 or $250,000 if the person is planning to join Medicare within 30 months.
- Misusing WCMSA funds for non-related expenses can lead to claim denials and reimbursement obligations.
Final Thoughts
Workers' compensation provides insurance for work-related injuries and illnesses for federal employees and certain other groups. To prevent complications with medical expenses, those enrolled in Medicare or about to join should be aware of how workers' compensation might impact their coverage and inform Medicare about workers' compensation arrangements to avoid potential claim rejections and reimbursement obligations.
Medicare Resources
Feeling overwhelmed? Head on over to our Medicare hub to access more resources aimed at demystifying the complex world of medical insurance.
- Medicare is involved in the medical expenses of those who've suffered work-related injuries or illnesses, particularly for federal workers and select entities.
- For treatment of job-related injuries, workers' compensation should be the primary payer, but Medicare may step in if immediate expenses arise before workers' compensation settlement.
- To avoid Medicare's recovery process, the Centers for Medicare & Medicaid Services (CMS) must be informed of funds received from workers' compensation for injury-related medical care.
- In some cases, Medicare may ask for the creation of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds, covering care only after the WCMSA funds are depleted.
- Total Payment Obligation to the Claimant (TPOC) must be submitted to CMS for Medicare to cover the correct portion of a person's medical expenses, regardless of enrollment status.
- Individuals should report all liability or no-fault insurance claims to Medicare, even if they're not currently enrolled in Medicare but will soon be eligible.
