Worker's Compensation and Medicare: Essential Information
Nailing down the details when Medicare and workers' comp intersect is a must. Neglecting to do so might lead to claim denials and having to shell out cash to Medicare.
Workers' comp is a life-saver for employees dealing with injuries or ailments stemming from their nine-to-five. The Office of Workers' Compensation Programs (OWCP), nestled under the Department of Labor, administers this service for federal employees, their loved ones, and other eligible entities.
Comprehending how a workers' comp settlement could influence Medicare coverage is paramount, especially for people currently enrolled or soon-to-be enrollees in Medicare. This can help circumvent unnecessary dilemmas related to medical costs attributed to work-related issues.
So, how does a workers' comp settlement impact Medicare?
Under Medicare's secondary payer policy, workers' comp needs to be the lead payer for any medical treatment connected to a work-related injury.
In emergency situations where the person hasn't collected their comp settlement yet, Medicare might pick up the tab initially, initiating a recovery process carried out by the Benefits Coordination & Recovery Center (BCRC). To avoid entanglements in this process, the Centers for Medicare & Medicaid Services (CMS) typically monitors the amount received from workers' comp for injury or illness-related medical care. In some instances, Medicare might ask for a workers' comp Medicare set-aside arrangement (WCMSA) for these funds. Medical care would only be covered once the WCMSA is depleted.
When should workers' comp settlements be reported to Medicare?
Workers' comp must submit a total payment obligation to the claimant (TPOC) to CMS to make sure Medicare covers the right portion of medical expenses. This total represents the overall amount owed to the person or on their behalf.
This reporting is essential for people already in Medicare due to age or Social Security Disability Insurance, provided the settlement exceeds $25,000.
Additionally, if the person is not enrolled in Medicare yet but will within 30 months of the settlement date and the settlement amount surpasses $250,000, TPOCs should be submitted.
Bear in mind that a person needs to report not only workers' comp settlements but also liability or no-fault insurance claims to Medicare.
FAQ
To inquire about anything related to Medicare, contact Medicare at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During specific hours, a live chat is available on Medicare.gov. If you have questions about the Medicare recovery process, connect with the BCRC at 855-798-2627 (TTY 855-797-2627).
A WCMSA is optional, but if a Medicare beneficiary decides to establish one, the workers' comp settlement must top $25,000 or $250,000 if they become eligible for Medicare within 30 months.
Using the funds in a WCMSA for purposes other than those designated can lead to claim denials and the obligation to reimburse Medicare.
- The Office of Workers' Compensation Programs (OWCP) administers workers' comp for federal employees and eligible entities, but understanding how a workers' comp settlement impacts Medicare is crucial.
- Under Medicare's secondary payer policy, workers' comp is the lead payer for any medical treatment related to a work-related injury, and the Centers for Medicare & Medicaid Services (CMS) monitors the amount received from workers' comp for injury-related medical care.
- In some cases, Medicare might ask for a workers' comp Medicare set-aside arrangement (WCMSA) for these funds, stipulating that medical care would only be covered once the WCMSA is depleted.
- Workers' comp must submit a total payment obligation to the claimant (TPOC) to CMS, especially for people already in Medicare due to age or Social Security Disability Insurance, if the settlement exceeds $25,000.
- If the person is not enrolled in Medicare yet but will within 30 months of the settlement date and the settlement amount surpasses $250,000, TPOCs should be submitted.
- It is important to note that a person needs to report not only workers' comp settlements but also liability or no-fault insurance claims to Medicare for proper coverage and to avoid claim denials and the obligation to reimburse Medicare.
