Medicare and Workers' Compensation Intersection: Crucial Facts Explained
Navigatingworkers' compensation and Medicare can be a tricky business. It's vital to be in the know if you're already enrolled in Medicare, planning to, or you're a federal employee or part of a specific entity that qualifies for workers' compensation benefits.
Workers' comp is here to help cover your medical expenses when you've been injured or fallen ill directly due to your job. The Office of Workers' Compensation Programs (OWCP) handles this under the Department of Labor.
When it comes to Medicare coverage, keep in mind that workers' compensation ought to be the primary payer for any work-related injury treatment. If you incur expenses before receiving your workers' comp settlement, Medicare might pay first and start a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To avoid this, the Centers for Medicare & Medicaid Services (CMS) usually keeps an eye on the funds you receive from workers' compensation for your injury-related medical expenses.
Sometimes, Medicare may ask for a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. They will only cover your care once all the money in the WCMSA has been used up.
So, what should you report to Medicare? A total payment obligation to the claimant (TPOC) needs to be submitted to CMS by workers' compensation if you're currently enrolled in Medicare or will soon qualify, and the settlement is $25,000 or more. Or, if you're not yet enrolled in Medicare but will be within 30 months of the settlement date and the settlement amount is $250,000 or more. You should also report if you file a liability or no-fault insurance claim.
Worried you've missed something? You can reach out to Medicare through phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or during certain hours via live chat on Medicare.gov. If you have questions about the Medicare recovery process, call the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary, but if you want to set one up, your workers' comp settlement must be over $25,000 or over $250,000 if you're eligible for Medicare within 30 months. Also, it's important to note that it's prohibited to use the money from an MSA for anything other than its designated purpose, as misusing it can lead to claim denials and reimbursement obligations.
Now, you might be wondering about who actually reports the settlement to CMS. Well, typically it's the primary payer — i.e., the insurance company or claims administrator — under the requirements of the Medicare Secondary Payer (MSP) Mandatory Reporting provisions of the Medicare and Medicaid SCHIP Extension Act. They use the Section 111 reporting process to do so and report detailed information like the nature of the injury, parties involved, settlement or award terms, and personal identifying information of the claimant.
With all this in mind, it's essential to manage your workers' comp and Medicare benefits effectively to avoid any future claim rejections or reimbursement obligations. For more resources, head over to our Medicare hub!
- Medicare should ideally be the secondary payer for any therapies and treatments related to a work-related injury, as workers' compensation is expected to be the primary payer.
- When receiving a workers' compensation settlement of $25,000 or more, it's mandatory to report the total payment obligation to the claimant (TPOC) to the Centers for Medicare & Medicaid Services (CMS), especially if you're already enrolled in Medicare or will soon qualify.
- In some cases, Medicare may require a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) for injury-related medical expenses, and will cover your care only after all the money in the WCMSA has been exhausted.
- A Medicare set-aside is voluntary, but it's essential to use the money within the arrangement only for its designated purpose, as misusing it can result in claim denials and reimbursement obligations.
- The primary payer, whether an insurance company or claims administrator, is typically responsible for reporting the settlement details to CMS under the requirements of the Medicare Secondary Payer (MSP) Mandatory Reporting provisions of the Medicare and Medicaid SCHIP Extension Act, using the Section 111 reporting process.
