Nailing Down the Nitty-Gritty of Workers' Compensation and Medicare Coordination
Understanding the Interplay Between Workers' Compensation and Medicare: Essential Facts to Grasp
Navigating the maze of workers' compensation and Medicare isn't a walk in the park, but understanding the ins and outs can save a heap of headaches down the line.
Workers' compensation is an insurance policy that kicks in when employees sustain injuries or illnesses related to their jobs. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor manages this benefit for federal employees, their loved ones, and certain other entities.
If you're on Medicare or heading that way, it's essential to grasp how workers' compensation may impact Medicare's coverage of your healthcare claims. By doing so, you can dodge complications when it comes to covering medical expenses for job-related injuries or illnesses.
The Lowdown on Workers' Comp Settlements and Medicare
Under Medicare's secondary payer policy, workers' compensation should take the lead role when it comes to covering treatment for work-related injuries. However, if immediate medical costs come up before you receive your workers' compensation settlement, Medicare may foot the bill initially and start a recovery process run by the Benefits Coordination & Recovery Center (BCRC). To avoid this process, The Centers for Medicare & Medicaid Services (CMS) often monitors the amount you receive from workers' compensation for medical expenses related to your workplace injury. In certain cases, Medicare might request the creation of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover the expenses after exhausting the WCMSA funds.
The Settlements That Need to Go on Medicare's Radar
When it comes to workers' compensation settlements, Medicare requires the Total Payment Obligation to the Claimant (TPOC) to be filed with CMS. This is crucial if you're already on Medicare based on age or SSDI, and the settlement amount exceeds $25,000. It's also needed if you aren't enrolled in Medicare but are eligible within 30 months of the settlement date, and the settlement amount is $250,000 or more.
Moreover, if you file a liability or no-fault insurance claim, you must also report it to Medicare.
Frequently Asked Questions
To get your questions answered, you can contact Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During specific hours, a live chat is available on Medicare.gov. If you have queries about the Medicare recovery process, you can reach the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary. However, you'll need a settlement over $25,000 if you want to set one up and are a Medicare beneficiary, or have an eligible package for Medicare within 30 months.
Yes, misusing the funds in a Medicare set-aside arrangement can lead to claim denials and reimbursing Medicare.
Learn more: What to know about Medicare set-aside
"Takeaway"
Workers' compensation provides benefits for job-related injuries or illnesses for federal employees and certain other groups.
It's essential that those on Medicare or soon to be enrolled become acquainted with how workers' compensation may impact their Medicare benefits to avoid issues with medical expenses.
Proactively reporting workers' compensation agreements to Medicare helps avoid future claim rejections and reimbursement obligations.
Medicare resources
For more resources to help you traverse the intricate world of medical insurance, visit our Medicare hub.
- Medicare requires the Total Payment Obligation to the Claimant (TPOC) to be filed with them if you are on Medicare based on age or SSDI, and the settlement amount exceeds $25,000.
- In cases where you aren't enrolled in Medicare but are eligible within 30 months of the settlement date, and the settlement amount is $250,000 or more, you also need to file the TPOC with Medicare.
- If you file a liability or no-fault insurance claim, it is necessary to report it to Medicare as well.
- A Medicare set-aside is voluntary, but if you have a settlement over $25,000 and are a Medicare beneficiary, or have an eligible package for Medicare within 30 months, you'll need to create a Medicare set-aside arrangement (WCMSA).
- Misusing the funds in a Medicare set-aside arrangement can lead to claim denials and reimbursement obligations.
- Understanding how workers' compensation may impact your Medicare benefits is crucial, as it will help you avoid issues with medical expenses for job-related injuries or illnesses.
