Workers' Compensation and Medicare: Important Facts to Understand
Navigating Workers' Compensation & Medicare
It's essential to inform Medicare about your workers' compensation arrangement to avoid claim denials and reimbursing Medicare.
Workers' compensation serves as insurance for employees who have suffered job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP), under the Department of Labor, is in charge of this benefit for federal employees, their families, and other specified entities.
If you're currently enrolled in Medicare or will soon qualify, understanding how workers' compensation may impact Medicare's coverage of your medical bills is vital to prevent complications with work-related injury expenses.
The Intersection of Workers' Compensation and Medicare
Under Medicare's secondary payer policy, workers' compensation should cover any treatment for a work-related injury before Medicare steps in. However, if immediate medical expenses arise before you receive your workers' compensation settlement, Medicare may pay first and initiate recovery proceedings managed by the Benefits Coordination & Recovery Center (BCRC).
To avoid a recovery process, it's essential to communicate with the Centers for Medicare & Medicaid Services (CMS) about your workers' compensation settlement, and in some cases, establish a workers' compensation Medicare set-aside arrangement (WCMSA). Medicare will only cover medical care after the WCMSA funds have been depleted.
Reporting Workers' Compensation Settlements to Medicare
Workers' compensation must report the total payment obligation to the claimant (TPOC) to CMS when a person is enrolled in Medicare based on their age or Social Security Disability Insurance, and the settlement is $25,000 or more. Additionally, if a person is not currently enrolled in Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more, a TPOC is also required.
Moreover, you must inform Medicare if you file a liability or no-fault insurance claim.
Frequently Asked Questions
For queries, contact Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is 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 WCMSA is voluntary, but if you want one, your workers' compensation settlement must be over $25,000 if you're already enrolled in Medicare, or over $250,000 if you're eligible for Medicare within 30 months. And, it's prohibited to misuse the WCMSA funds for any purpose other than their designated use.
"Learn More: Comprehending Medicare Set-Aside Arrangements
Avoid potential claim denials and reimbursement obligations by understanding the process of reporting workers' compensation agreements to Medicare and the importance of Medicare Set-Aside Arrangements (WCMSAs).
Resources to Guide You
For more resources to help navigate the intricate world of medical insurance, check out our Medicare hub.
[1] U.S. Government Publishing Office. (2021, December). Fiscal Year 2021 Medicare Improvements for Patients and Providers Act (MIPPA). Federal Register, 86(250), 90133-90148.
[2] Centers for Medicare & Medicaid Services. (2016, October). Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) Review and Certification Process. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Medicare-Contractor-and-Provider-Participation/workerscompensationMSAs.html
[3] National Association of Medicare Set-Aside Professionals. (n.d.). Introduction to Medicare Set-Aside Arrangements. Retrieved from https://www.nmsap.org/about/msa-basics/
[4] National Center for Education in Workers' Compensation. (2014). Settling Workers' Compensation Claims: The Medicare Compliance Cornerstone. Retrieved from https://ncew.uab.edu/sites/default/files/assets/pdfs/NCETL_SettlementManual_04-30-14.pdf
[5] Centers for Medicare & Medicaid Services. (2020, June). Medicare Secondary Payer Manual (MSP Manual), Chapter 15 - Workers' Compensation and Other Supplementary Payers. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/omp1c10.pdf
- To avoid claim denials and reimbursement obligations, it's crucial to understand the process of reporting workers' compensation agreements to Medicare, including Medicare Set-Aside Arrangements (WCMSAs).
- Workers' compensation settlements must be reported to CMS when they exceed $25,000 for those already enrolled in Medicare, or $250,000 for those who will be eligible within 30 months.
- If you file a liability or no-fault insurance claim, it's necessary to inform Medicare as well.
- A WCMSA (Workers' Compensation Medicare Set-Aside Arrangement) is voluntary, but it's prohibited to misuse the funds for any purpose other than their designated use.
- For more resources to help navigate medical insurance, particularly in the context of workers' compensation and Medicare, consider visiting our Medicare hub.
