Medicare and Workers' Compensation: Key Insights
Important Notice: Failing to Inform Medicare About Workers' Compensation Arrangements Can Lead to Claim Denials and Repayment Obligations
Workers' compensation serves as insurance for employees who sustain work-related injuries or illnesses. This liability falls under the Office of Workers' Compensation Programs (OWCP) within the Department of Labor, providing benefits to federal employees, their families, and certain other entities.
Individuals enrolled in Medicare or approaching eligibility must understand the potential implications of workers' compensation on their Medicare coverage. This knowledge is crucial to avoid complications in managing medical expenses related to workplace injuries or illnesses.
Understanding Workers' Compensation Settlements and Their Impact on Medicare:
In accordance with Medicare's secondary payer policy, workers' compensation should always be the primary payer for any treatment related to a work-related injury. However, if immediate medical expenses arise prior to receiving the workers' compensation settlement, Medicare may cover the initial costs and initiate a recovery process through the Benefits Coordination & Recovery Center (BCRC).
To prevent such recovery processes, the Centers for Medicare & Medicaid Services (CMS) monitors the amount a person receives from workers' compensation for medical care related to their injury or illness. In some instances, Medicare may request the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds, only covering care after the WCMSA funds have been fully expended.
Workers' Compensation Settlements That Require Reporting to Medicare:
Workers' compensation must submit a Total Payment Obligation to the Claimant (TPOC) to CMS to ensure Medicare covers the appropriate portion of an individual's medical expenses. This submission is mandatory for those already enrolled in Medicare based on age or Social Security Disability Insurance (SSDI), as well as for those who will qualify for Medicare within 30 months of the settlement date, with settlement amounts exceeding $250,000. Additionally, TPOCs are necessary if the settlement amount is $25,000 or higher for individuals already enrolled in Medicare, or those who are not yet eligible but will be within 30 months and the settlement amount is $250,000 or more. Moreover, filing a liability or no-fault insurance claim necessitates reporting to Medicare as well.
Answers to Frequently Asked Questions:
- To address any questions or concerns, individuals may contact Medicare at 800-MEDICARE (800-633-4227), or TTY 877-486-2048 during certain hours. Live chat support is available on Medicare.gov. For inquiries regarding the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
- A Medicare set-aside is voluntary, but it is essential for beneficiaries with workers' compensation settlements exceeding $25,000 ($250,000 if they will qualify for Medicare within 30 months) to report these to Medicare.
- Misusing funds from a Medicare set-aside arrangement can result in claim denials and a requirement to reimburse Medicare.
essential to ensure Medicare's interest is protected and to avoid potential complications in managing medical expenses related to workplace injuries or illnesses. Familiarize yourself with the reporting requirements to avoid claim denials, repayment obligations, and potential penalties.
To protect Medicare's interest and manage medical expenses related to workplace injuries effectively, it's essential to understand the reporting requirements for workers' compensation settlements. Individuals who have workers' compensation settlements exceeding $25,000 ($250,000 if they will qualify for Medicare within 30 months) must submit a Total Payment Obligation to the Claimant (TPOC) to Medicare. This is necessary for those already enrolled in Medicare based on age or Social Security Disability Insurance (SSDI), as well as for those approaching Medicare eligibility. Failing to report can lead to claim denials, repayment obligations, and potential penalties, making healthsystems awareness of these processes crucial in the health-and-wellness and science-based approach to Medicare coverage.
