Medicare and workers' compensation: Key insights to consider
Rewritten Article:
Understanding the connection between workers' compensation and Medicare is vital. Neglecting to inform Medicare about workers' compensation arrangements can lead to claim denials and unnecessary reimbursements.
Workers' compensation serves as insurance for those who have suffered job-related injuries or illnesses, with the Office of Workers' Compensation Programs (OWCP) overseeing this benefit, primarily for federal employees, their families, and other eligible entities.
As Medicare beneficiaries, it's essential to grasp the implications that workers' compensation may have on the coverage of medical claims related to work-related injuries. This knowledge helps prevent complications when it comes to medical expenses incurred through work injuries.
How does a workers’ comp settlement interfere with Medicare?
Medicare operates as a secondary payer for treatment related to a work injury. However, if immediate medical expenses arise before a workers' compensation settlement is received, Medicare may cover these costs initially and then initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To avoid the recovery process and complications, the Centers for Medicare & Medicaid Services (CMS) strives to monitor the amount an individual receives from workers' compensation for injuries or illness-related medical care. In some cases, Medicare may suggest creating a Workers' Compensation Medicare Set-Aside Agreement (WCMSA) for these funds. Medicare will only cover the cost of care after the entire WCMSA has been depleted.
Which settlements need to be reported to Medicare?
Workers' compensation must submit the Total Payment Obligation to the Claimant (TPOC) to CMS, which signifies the total amount owed to the individual or on their behalf. The TPOC must be submitted if the individual is already enrolled in Medicare based on their age or SSDI and the settlement is $25,000 or more.
Additionally, if the person is not enrolled in Medicare but will qualify for the program within 30 months of the settlement date and the settlement amount is $250,000 or more, a TPOC must be submitted. Besides workers' comp, a person should also report to Medicare if they file a liability or no-fault insurance claim.
Common Questions
You can reach out to Medicare for any questions by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, live chat is also available on Medicare.gov. If you have questions about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is optional. However, if a beneficiary wishes to set one up, the workers' compensation settlement must be over $25,000. Alternatively, it needs to be over $250,000 if the person is eligible for Medicare within 30 months.
Yes, it's prohibited to use the funds in a Medicare set-aside arrangement, such as a WCMSA, for anything other than the designated purpose. Misusing these funds may lead to claim denials and reimbursement obligations.
"Learn more: What You Need to Know About Medicare Set-Asides"
Takeaway
Workers' compensation provides insurance coverage for job-related injuries or illnesses for eligible groups.
To prevent issues with medical expenses for Medicare beneficiaries, it's crucial to educate yourself on the implications of workers' compensation on Medicare coverage.
Also, be sure to inform Medicare about workers' compensation agreements to avoid future claim rejections and reimbursement obligations.
- The connection between workers' compensation and Medicare is vital to understand, as failing to inform Medicare about such arrangements can lead to claim denials and unnecessary reimbursements.
- Workers' compensation serves as insurance for those who have suffered job-related injuries or illnesses, with the Office of Workers' Compensation Programs (OWCP) overseeing this benefit for federal employees, their families, and other eligible entities.
- Medicare operates as a secondary payer for treatment related to work-related injuries, but if an individual receives immediate medical expenses before the workers' compensation settlement, Medicare may cover these costs initially.
- To avoid complications, the Centers for Medicare & Medicaid Services (CMS) monitors the amount an individual receives from workers' compensation for injuries or illness-related medical care, and may suggest creating a Workers' Compensation Medicare Set-Aside Agreement (WCMSA) for these funds.
- Workers' compensation must submit the Total Payment Obligation to the Claimant (TPOC) to CMS if the individual is already enrolled in Medicare based on their age or SSDI, and the settlement is $25,000 or more.
- If a person is not enrolled in Medicare but will qualify for the program within 30 months of the settlement date and the settlement amount is $250,000 or more, a TPOC must be submitted, and the individual should also report to Medicare if they file a liability or no-fault insurance claim.
