Navigating workers' compensation and Medicare concurrently: Essential insights
Prompt Compliance Essential for Workers' Compensation and Medicare
Workers' compensation insurance benefits are crucial for employees who suffer job-related injuries or illnesses, providing coverage under the Office of Workers' Compensation Programs (OWCP) within the Department of Labor. This insurance applies not only to federal employees but also to their families and certain other entities.
Individuals enrolled in Medicare or those who will soon qualify for the program need to understand the potential impact of workers' compensation benefits on their Medicare coverage. This understanding is vital to prevent complications with medical costs resulting from work-related injuries or illnesses.
Workers' Compensation Settlements and Medicare Coverage
Under Medicare's secondary payer policy, workers' compensation must be the primary payer for any treatment related to a work-related injury. However, if immediate medical expenses arise before an individual receives their workers' compensation settlement, Medicare may cover the initial expenses and initiate a recovery process managed 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) for these funds, covering care only after the exhaustion of the WCMSA funds.
Reporting Settlements to Medicare
Workers' compensation must submit a total payment obligation to the claimant (TPOC) to CMS to ensure Medicare covers the appropriate portion of a person's medical expenses. This submission is necessary for enrolled Medicare recipients based on age or Social Security Disability Insurance, as well as for those who will qualify for Medicare within 30 months and have settlements exceeding $250,000.
In addition to workers' comp, a person must report to Medicare if they file a liability or no-fault insurance claim.
The FAQ section below highlights relevant resources and answers to common questions about this topic.
Frequently Asked Questions
Questions can be directed to Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During select hours, a live chat is available on Medicare.gov. For questions about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary but may be required if a person's workers' compensation settlement exceeds $25,000 or, if the person becomes Medicare-eligible within 30 months, exceeds $250,000.
It is prohibited to use the money in a Medicare set-aside arrangement for any purpose other than its designated use, as misuse can lead to claim denials and reimbursement obligations.
For further resources to navigate the intricacies of medical insurance, visit our Medicare hub.
Takeaway
Workers' compensation insurance provides financial support for job-related injuries or illnesses for federal employees and select others. It is essential for individuals enrolled in Medicare or approaching eligibility to educate themselves on the potential impact of workers' compensation on their Medicare coverage to avoid issues with medical expenses.
It is crucial to report workers' compensation agreements to Medicare to avoid future claim rejections and reimbursement obligations.
- Medicare's secondary payer policy requires workers' compensation to be the primary payer for any treatment related to a work-related injury.
- Individuals with workers' compensation settlements exceeding $25,000 may need to establish a Medicare set-aside arrangement (WCMSA) for medical care.
- For a proper allocation of medical expenses, workers' compensation must submit a total payment obligation to the claimant (TPOC) to Medicare when settlements exceed $250,000 or the individual becomes Medicare-eligible within 30 months.
- Avoiding medicare reimbursement obligations necessitates reporting workers' compensation agreements and settlements to Medicare, including liability or no-fault insurance claims.
