Medicare and Workers' Compensation: Essential Insights
Preparingfor a workers' compensation claim while on Medicare is essential to avoid claim denials and reimbursement obligations. After all, workers' compensation serves as insurance for job-related injuries or illnesses for federal employees and certain other groups.
Here's a refresher on how workers' comp interacts with Medicare:
- Workers' comp is the primary payer for any treatment related to a work-related injury under Medicare's secondary payer policy.
- In case of immediate medical expenses prior to workers' comp settlement, Medicare may pay first to initiate a recovery process handled by the Benefits Coordination & Recovery Center (BCRC).
- To avoid a recovery process, the Centers for Medicare & Medicaid Services (CMS) generally monitors the amount a person receives from workers' compensation for injury or illness-related medical care. In some cases, Medicare may ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA).
Now, let's discuss what settlements need to be reported to Medicare:
- The Office of Workers' Compensation Programs (OWCP) must submit a Total Payment Obligation to the Claimant (TPOC) to CMS if the person is currently enrolled in Medicare or will soon qualify for the program, and the settlement is over $25,000 (or $250,000 if they will qualify within 30 months).
- TPOCs are also necessary for filing a liability or no-fault insurance claim.
For frequently asked questions and further resources, you can reach out to Medicare at 800-MEDICARE (TTY 877-486-2048) or through live chat on Medicare.gov. If you have questions about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
It's important to note that a Medicare Set-Aside is voluntary. However, if a Medicare beneficiary wants to set one up, their workers' compensation settlement must exceed $25,000 (or $250,000 if they will qualify for Medicare within 30 months). Misusing the funds in a Medicare Set-Aside Arrangement can lead to claim denials and reimbursement obligations.
In the near future, starting April 4, 2025, Medicare will require all full and final workers' compensation settlements involving Medicare beneficiaries to be reported to the Centers for Medicare & Medicaid Services (CMS), even if a Medicare Set-Aside Arrangement (MSA) is not requested or the settlement is below certain monetary thresholds. The reporting responsibility lies with the workers' compensation payer or the Responsible Reporting Entity (RRE), not the Medicare beneficiary. The CMS uses this information to protect Medicare's interests and ensure proper coordination of benefits for future injury-related medical expenses.
- In the case of a workers' compensation settlement exceeding $25,000 (or $250,000 if the employee will qualify for Medicare within 30 months), the Office of Workers' Compensation Programs (OWCP) must submit a Total Payment Obligation to the Claimant (TPOC) to the Centers for Medicare & Medicaid Services (CMS), as part of the health systems' unfolding policies.
- Under the science of workplace-wellness, understanding medical-conditions is crucial for employers and employees alike, as it helps in the coordination of benefits between Medicare and workers' compensation, ensuring health-and-wellness for all parties involved.
- As of April 4, 2025, the new regulation mandates all full and final workers' compensation settlements involving Medicare beneficiaries to be reported to the Centers for Medicare & Medicaid Services (CMS), even if a Medicare Set-Aside Arrangement (MSA) is not requested or the settlement is below certain monetary thresholds, to safeguard Medicare's interest in the unfolding healthsystems landscape.
