Medicare and Workers' Compensation: Essential Facts You Need to Understand
Working with Medicare and Workers' Compensation: A Comprehensive Guide
Navigating the intersection of workers' compensation and Medicare can be tricky, but it's crucial to understand the implications but don't worry, we've got your back!
Workers' compensation offers protection to employees who suffer job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor handles this benefit for federal employees, their families, and various entities.
If you're enrolled in Medicare or approaching that milestone, it's essential to grasp how your workers' compensation benefits might impact Medicare's coverage of medical claims associated with work-related incidents. This knowledge helps avoid complications with medical costs resulting from on-the-job injuries or illnesses.
Understanding Workers' Compensation Settlements and Medicare
Under Medicare's secondary payer policy, workers' compensation must cover the primary expenses related to any treatment for a work-related injury. However, if immediate medical expenses arise prior to receiving your workers' compensation settlement, Medicare might pay first and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To prevent a recovery process and ensure seamless coverage, the Centers for Medicare & Medicaid Services (CMS) frequently monitors the amount a person receives from workers' compensation for their injury or illness-related medical care. In some instances, Medicare may request the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover care once all the money in the WCMSA has been utilized.
Reporting Requirements for Workers' Compensation Settlements to Medicare
Workers' compensation is obligated to submit a Total Payment Obligation to the Claimant (TPOC) to CMS to guarantee that Medicare covers the appropriate portion of a person's medical expenses. This TPOC represents the total amount that workers' compensation owes to the person or on their behalf.
TPOC submission is necessary when a person is already enrolled in Medicare due to age or Social Security Disability Insurance, and the settlement value surpasses $25,000.
Additionally, TPOC submission is required if the person is not yet enrolled in Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or greater.
Reporting isn't limited to workers' comp—in case of liability or no-fault insurance claims, the person must also inform Medicare.
Frequently Asked Questions
You can contact Medicare with questions via phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is also available on Medicare.gov. For queries about the Medicare recovery process, reach out to the BCRC at 855-798-2627 (TTY 855-797-2627).
A WCMSA is voluntary, but if you wish to set one up, your workers' compensation settlement must exceed $25,000 or $250,000 if you're eligible for Medicare within 30 months. Misusing the funds in a WCMSA for purposes other than designated is strictly prohibited and may lead to claim denials and reimbursement obligations.
"More Information: What to know about Medicare set-aside"
The Bottom Line
Workers' compensation serves as insurance for job-related injuries or illnesses for federal employees and specific groups.
For those enrolled in Medicare or approaching eligibility, it's crucial to familiarize yourself with how workers' compensation may impact your Medicare coverage to prevent issues with medical costs linked to work-related incidents.
Lastly, remember to keep Medicare informed about workers' compensation agreements to avoid future claim rejections and reimbursement obligations.
Useful Resources
Visit our Medicare hub for more resources that can help navigate the complex world of medical insurance.
- To ensure seamless coverage for medical conditions arising from job-related incidents, it's important to understand that under Medicare's secondary payer policy, workers' compensation should cover primary expenses related to such treatment.
- In instances where immediate medical expenses arise prior to receiving a workers' compensation settlement, Medicare might pay first and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
- If the Office of Workers' Compensation Programs (OWCP) provides a Total Payment Obligation to the Claimant (TPOC) to the Centers for Medicare & Medicaid Services (CMS), Medicare can cover the appropriate portion of a person's medical expenses.
- When a person is already enrolled in Medicare or will qualify within 30 months of the settlement date and the settlement value surpasses $25,000, TPOC submission is necessary.
- When discussing workers' compensation, remember that misusing funds in a Medicare Set-Aside Arrangement (WCMSA) for purposes other than designated is strictly prohibited and may lead to claim denials and reimbursement obligations.
