Medicare and Workers' Compensation: Key Facts to Understand
Navigating the intersection of workers' compensation and Medicare is a must for eligible personnel. Neglecting to inform Medicare about a workers' comp arrangement could lead to claim denials and the requirement to repay Medicare.
Workers' compensation offers coverage for employees who incur injuries or illnesses directly due to their jobs. The Office of Workers' Compensation Programs (OWCP) overseen by the Department of Labor administers this benefit for federal employees, their families, and select others.
People currently enrolled in Medicare or nearing this stage in their life should familiarize themselves with how workers' comp might impact Medicare's coverage of their medical bills. This is vital for avoiding future complications with work-related medical costs.
How does a workers' comp settlement impact Medicare?
Under Medicare's secondary payer policy, workers' comp should cover any treatment for work-related injuries. If immediate expenses arise before the settlement, though, Medicare may temporarily pay for the treatment and initiate a Benefits Coordination & Recovery Center (BCRC) process to recover the costs.
To avoid this recovery process and maintain financial clarity, the Centers for Medicare & Medicaid Services (CMS) typically aims to monitor the funds received from workers' comp for injury-related medical care. In some cases, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) to manage these funds properly.
What settlements need to be reported to Medicare?
Workers' comp is required to submit a Total Payment Obligation to Claimant (TPOC) to CMS for any settlement valued at $25,000 or more. This TPOC ensures that Medicare covers the appropriate portion of a person's medical expenses when they're already enrolled in Medicare based on their age or due to receiving Social Security Disability Insurance.
Similarly, if a person is not yet enrolled in Medicare but will be within 30 months of the settlement date, and the settlement exceeds $250,000, a TPOC must be submitted. Additionally, it's necessary to report liability or no-fault insurance claims to Medicare.
FAQ
Questions regarding Medicare can be directed to Medicare by phone at 800-MEDICARE (800-633-4227), or during specific hours, live chat is available on Medicare.gov. For queries about the Medicare recovery process, contact the BCRC at 855-798-2627.
A Medicare set-aside is optional, but it becomes necessary if the workers' comp settlement surpasses $25,000 for current Medicare beneficiaries, or $250,000 for those eligible within 30 months. Misusing funds from a Medicare set-aside may result in claim denials or reimbursement requirements.
Key Takeaways
Workers' compensation offers insurance for job-related injuries or illnesses and is relevant to federal employees and specific groups.
Current or soon-to-be Medicare beneficiaries should educate themselves on how workers' comp might impact their Medicare coverage to prevent issues with medical expenses and potential reimbursement obligations.
Clear communication about workers' comp agreements with Medicare is essential to maintain proper coverage and avoid future claims rejections or repayment obligations.
- Workers' compensation (WC) should cover any treatment for work-related injuries, but if immediate expenses arise before the settlement, Medicare may temporarily pay for the treatment and subsequently recover the costs.
- Under Medicare's rules, workers' comp is required to submit a Total Payment Obligation to Claimant (TPOC) to Medicare for any settlement valued at $25,000 or more, to ensure Medicare covers the appropriate portion of a person's medical expenses.
- In some cases, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) to manage funds properly for injury-related medical care, especially when the settlement exceeds $25,000 for current Medicare beneficiaries or $250,000 for those eligible within 30 months.
- If a person is not yet enrolled in Medicare but will be within 30 months of the settlement date, and the settlement exceeds $250,000, a TPOC must be submitted, along with reporting liability or no-fault insurance claims to Medicare.
