Medicare and Workers' Compensation Crossover: Essential Facts to Understand
The Scoop on Medicare and Workers' Compensation
Dealing with workers' comp while on Medicare can get tricky. If you fail to disclose a workers' comp arrangement, you might encounter claim denials and need to repay Medicare.
Workers' comp offers financial aid to employees who've suffered job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor manages this perk for federal workers, their families, and other entities.
If you're enrolled in Medicare or planning to be soon, it's crucial to understand how workers' comp might impact Medicare's coverage of your medical claims. This is key to steer clear of conflicts with work-related medical costs.
Workers' Comp Settlements and Medicare: What's the Deal?
Under Medicare's secondary payer policy, workers' comp should pay for any treatment connected to a work injury before Medicare jumps in.
But let's say immediate medical bills crop up before you receive your workers' comp settlement. In that case, Medicare might cough up the cash first and then initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). Preventing this recovery process is where things get interesting. To achieve this, the Centers for Medicare & Medicaid Services (CMS) keeps an eye on the money you get from workers' comp for your injury-related medical expenses.
In specific cases, Medicare might request the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover treatments after the WCMSA funds have been used up.
What Settlements Must Be Reported to Medicare?
Any settlement or judgment details, including WCMSA allocations, need to be reported to CMS. This is essential if:
- You're already enrolled in Medicare due to your age or receiving Social Security Disability Insurance. The settlement in question should be $25,000 or more.
- You're not yet enrolled in Medicare but will be within 30 months of the settlement date. The settlement amount should be $250,000 or more.
In addition to workers' comp, you'll need to report to Medicare if you file a liability or no-fault insurance claim.
Frequently Asked Questions
To get in touch with Medicare, call 800-MEDICARE (800-633-4227; TTY 877-486-2048). During particular hours, you can also chat live 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 voluntary, but if you have a workers' comp settlement over $25,000 or $250,000 if you'll be eligible for Medicare within 30 months, it's necessary. Misusing set-aside funds can lead to claim denials and the need for reimbursement to Medicare.
You might also like: What to know about Medicare set-asides
Final Word
Workers' comp is designed for job-related injuries or illnesses for federal employees and select groups.
To prevent hassles with medical expenses and claim denials, Medicare enrollees and soon-to-be enrollees should familiarize themselves with workers' comp's implications on their Medicare coverage. And, remember, reporting workers' comp arrangements is key to escaping future claim rejections and reimbursement obligations.
For more insight into the complex world of medical insurance, visit our Medicare hub.
- Medicare's secondary payer policy dictates that workers' comp should pay for any treatment related to a work injury before Medicare covers the costs.
- Any settlement or judgment details, including Workers' Compensation Medicare Set-Aside Arrangements (WCMSA), need to be reported to the Centers for Medicare & Medicaid Services (CMS) if the settlement is $25,000 or more for those already enrolled in Medicare, or $250,000 or more for those who will be enrolled within 30 months.
- To prevent claim denials and reimbursement obligations, it's essential for Medicare enrollees and soon-to-be enrollees to understand the implications of workers' comp on their health insurance coverage, and to report their workers' comp arrangements accordingly.
