Medicare and Workers' Compensation: Essential Information for Your Understanding
Workers' Comp and Medicare: A Must-Know Guide
Navigating the intersection of workers' compensation and Medicare is crucial, especially for federal employees and those soon qualifying for Medicare. Neglecting to do so could lead to claim denials and costly reimbursements.
Workers' compensation offers protection for those injured or ill due to job-related circumstances. This benefit, administered by the Office of Workers' Compensation Programs (OWCP), covers federal employees, their families, and specific other entities.
If you're currently enrolled in Medicare or planning to soon, it's vital to understand how workers' comp may impact your Medicare coverage. Preventing complications with medical expenses is key, particularly for work-related injuries.
Workers' Comp Settlements and Medicare
Under Medicare's secondary payer policy, workers' comp must oversee any treatment related to work injuries. If immediate medical care is required before the settlement is received, Medicare may provide initial coverage and initiate a recovery process via the Benefits Coordination & Recovery Center (BCRC).
To avoid such a recovery process, the Centers for Medicare & Medicaid Services (CMS) often monitors the amount an individual receives from workers' comp for injury-related medical care. In some cases, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds, covering medical expenses only after the WCMSA funds have been exhausted.
Settlements to Report to Medicare
Workers' comp must submit the Total Payment Obligation to the Claimant (TPOC) to Medicare when certain conditions are met. Specifically, if:
- The person is enrolled in Medicare due to age or Social Security Disability Insurance, and the settlement is $25,000 or more.
- The person will be eligible for Medicare within 30 months of the settlement date, and the settlement amount is $250,000 or more.
Additionally, if a person files a liability or no-fault insurance claim, it should also be reported to Medicare.
Frequently Asked Questions
You can reach out to Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or during specific hours, through live chat on Medicare.gov. For Medicare recovery process-related questions, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
Setting up a Medicare set-aside is voluntary, but if a Medicare beneficiary opts to do so, the settlement must exceed $25,000, or $250,000 if the individual will be Medicare-eligible within 30 months of the settlement date.
Using a Medicare set-aside arrangement's funds for purposes other than the designated ones can lead to claim denials and the need for Medicare reimbursement.
Takeaway
Understanding the intricacies between workers' comp and Medicare is paramount for federal employees and those soon to be eligible for Medicare. Properly reporting workers' comp settlements can prevent future claim rejections and unnecessary reimbursements to Medicare.
For comprehensive resources on navigating the complex world of medical insurance, explore our Medicare hub.
- The Medicare set-aside arrangement (WCMSA) is mandatory when a worker's compensation settlement exceeds $25,000 and the beneficiary is already enrolled in Medicare or will be within 30 months of the settlement date.
- Medicare offers coverage for immediate medical care required before the workers' comp settlement is received, but a recovery process may be initiated via the Benefits Coordination & Recovery Center (BCRC).
- Properly managing therapies and treatments within healthsystems, fall under the broad category of health-and-wellness, and can potentially be covered by workers' comp and Medicare, depending on the specifics of the case.
