Medicare and Workers' Compensation Interactions: Crucial Facts Explained
Importance of Informing Medicare about Workers' Compensation Settlements
Federal employees and other groups eligible for workers' compensation insurance should be aware of the implications of receiving benefits while enrolled in Medicare or soon to be eligible. Failure to notify Medicare about a workers' compensation arrangement may lead to claim denials and the need for reimbursement.
Workers' compensation provides coverage for injuries or illnesses directly related to one's job. Administered by the Office of Workers' Compensation Programs (OWCP) under the Department of Labor, this protection applies to federal employees, their families, and certain other entities.
Individuals currently on Medicare or approaching eligibility should understand how workers' compensation might affect Medicare's coverage of their medical claims for work-related injuries. Proper awareness can help prevent complications with medical expenses.
Understanding Workers' Compensation Settlements and Medicare
Medicare's secondary payer policy dictates that workers' compensation should be the primary payer for any work-related injury treatment. However, if immediate medical expenses arise before the worker receives their settlement, Medicare may pay first and subsequently initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To prevent such a recovery process, the Centers for Medicare & Medicaid Services (CMS) recommends monitoring the amount a person receives from workers' compensation for their injury or illness-related medical care. In some cases, Medicare may ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover care after all money in the WCMSA has been spent.
What Settlements Need to be Reported to Medicare?
Workers' compensation should submit a total payment obligation to the claimant (TPOC) to CMS to ensure Medicare covers the appropriate portion of a person's medical expenses. Submitting a TPOC is necessary if the person is already enrolled in Medicare based on their age or based on receiving Social Security Disability Insurance and if the settlement is $25,000 or more.
TPOCs are also necessary if the person is not currently enrolled in Medicare but will qualify for the program within 30 months of the settlement date, and the settlement amount is $250,000 or more. Additionally, people must report to Medicare if they file a liability or no-fault insurance claim.
FAQs
For questions or concerns, individuals can contact Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is also available on Medicare.gov. For queries about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary, but if a Medicare beneficiary wants to set one up, their workers' compensation settlement must be over $25,000 or over $250,000 if they are eligible for Medicare within 30 months. Misusing the funds in a Medicare set-aside can lead to claim denials and the need for reimbursement.
Key Points
- Workers' compensation insurance is for job-related injuries or illnesses for federal employees and certain groups.
- People enrolled in Medicare or soon to be eligible must understand how workers' compensation affects their Medicare coverage to avoid issues with medical expenses.
- Notifying Medicare about workers' compensation agreements is crucial to avoid claim rejections and reimbursement responsibilities.
For more resources to navigate the complex world of medical insurance, visit our Medicare hub.
- The Centers for Medicare & Medicaid Services (CMS) recommends monitoring the amount a person receives from workers' compensation for their injury or illness-related medical care to prevent a recovery process.
- Individuals must report to Medicare if they file a liability or no-fault insurance claim.
- A Medicare set-aside is voluntary, but if a Medicare beneficiary wants to set one up, their workers' compensation settlement must be over $25,000 or over $250,000 if they are eligible for Medicare within 30 months.
- Proper awareness of the implications of receiving workers' compensation benefits while enrolled in Medicare or soon to be eligible can help prevent complications with health systems, health-and-wellness, nutrition, therapies-and-treatments, and science-related expenses.
