Medicare and Workers' Compensation Interactions: Essential Facts
Rewritten Article:
Navigating workers' comp and Medicare can be a tricky business. Without proper reporting, you could face claim denials and the unpleasant task of reimbursing Medicare.
Workers' compensation is the insurance safety net for folks who've suffered job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP), nestled under the Department of Labor, is the one responsible for this benefit, which applies to federal employees, their families, and select other entities.
Individuals already enrolled in Medicare or soon-to-be enrollees need to grasp how workers' comp might impact Medicare's coverage of medical claims for work-related injuries. Knowing this will help dodge costly complications when it comes to medical bills due to work injuries.
The Intersection of Workers' Comp and Medicare
Medicare's secondary payer policy requires that workers' comp serves as the primary payer for any treatment related to a work injury. However, if you incur immediate medical expenses before receiving your workers' comp settlement, Medicare might pay first and kick off a recovery process handled by the Benefits Coordination & Recovery Center (BCRC).
To steer clear of a recovery process and ensure the Centers for Medicare & Medicaid Services (CMS) keeps tabs on the amount you receive from workers' comp for medical care related to your work injury, it's wise to inform CMS. In some cases, Medicare might ask you to establish a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare won't cover any care until the WCMSA funds run out.
What Needs Reporting?
Workers' comp must submit a Total Payment Obligation to the Claimant (TPOC) to CMS to ensure Medicare covers the necessary portion of your medical expenses. This amount represents the total workers' comp owed to you or on your behalf.
You'll need to submit a TPOC if you're currently enrolled in Medicare due to your age or receiving Social Security Disability Insurance, and the settlement is $25,000 or more.
TPOCs are also essential if you're not yet enrolled in Medicare but will be within 30 months of the settlement date, and the settlement amount exceeds $250,000.
Additionally, you'll need to report to Medicare if you file a liability or no-fault insurance claim.
Frequently Asked Questions
Call Medicare at 800-MEDICARE (800-633-4227, TTY 877-486-2048) if you've got questions. During certain hours, you can also chat with a representative on Medicare.gov. If you've questions about the Medicare recovery process, reach out to the BCRC at 855-798-2627 (TTY 855-797-2627).
An MSA is voluntary, but if you'd like to set one up, the workers' comp settlement must exceed $25,000 if you're already on Medicare, or $250,000 if you'll be eligible within 30 months.
Yes, misusing MSA funds for purposes other than those designated can result in claim denials and the need to reimburse Medicare.
"**Learn more: What to know about Medicare set-aside### Insights- Medicare's Medicare Secondary Payer (MSP) statute ensures Medicare's interests are protected, with the MSP requiring Medicare to remain the secondary payer for future medical costs related to settlements.- Medicare set-aside (MSA) arrangements are typically needed for Medicare-eligible individuals with settlements over $25,000 or those nearing eligibility with settlements exceeding $250,000.- As of April 4, 2025, workers' compensation payers must report MSA amounts in all settlements involving Medicare beneficiaries, regardless of the settlement size.
Takeaway
Workers' comp is insurance for job-related injuries or illnesses for federal employees and select groups. It's crucial that those enrolled in Medicare or soon-to-be eligible educate themselves on how workers' comp impacts their Medicare coverage to dodge medical expense hassles. Proper reporting of workers' comp arrangements to Medicare can help avoid future claim rejections and reimbursement obligations.
- Navigating workers' compensation and Medicare can involve complexities, particularly without correct reporting, which could lead to claim denials and the need for Medicare reimbursement.
- The Office of Workers' Compensation Programs (OWCP) is responsible for workers' compensation benefits, applicable to federal employees, their families, and certain other entities.
- Medicare's secondary payer policy mandates that workers' compensation serves as the primary payer for treatment related to work injuries, with Medicare stepping in if expenses are incurred before workers' comp settlement.
- To avoid a recovery process and ensure the Centers for Medicare & Medicaid Services (CMS) monitors workers' comp payments for work injury medical care, it's advisable to inform CMS and, in some cases, establish a workers' compensation Medicare set-aside arrangement (WCMSA).
- Workers' comp is required to submit a Total Payment Obligation to the Claimant (TPOC) to CMS for settlements exceeding $25,000 if the claimant is currently on Medicare, or $250,000 if they will be within 30 months, regardless of Medicare eligibility.
- Properly reporting workers' comp arrangements to Medicare can help avert future claim rejections and reimbursement obligations.
