Medicare and Workers' Compensation Interactions: Essential Information Explained
Workers' Compensation and Medicare: A Crucial Connection to Navigate
Navigating the intersection between workers' compensation and Medicare is essential to avoid claim denials and reimbursement obligations.
Workers' compensation serves as insurance for federal employees and other groups who suffer job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor oversees this benefit.
When someone enrolled in Medicare or approaching eligibility experiences a work-related injury or illness, understanding the potential impact on Medicare coverage becomes paramount to avoid complications with medical costs.
The Impact of a Workers' Compensation Settlement on Medicare
Under Medicare's secondary payer policy, workers' compensation must cover any treatment related to a work-related injury before Medicare steps in. However, if immediate medical expenses arise before settlement, Medicare may pay first and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To prevent a recovery process, Centers for Medicare & Medicaid Services (CMS) often monitor 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. Medicare will only cover care once all WCMSA funds have been exhausted.
Reporting Requirements for Workers' Compensation Settlements
Workers' compensation must submit a total payment obligation to the claimant (TPOC) to CMS to ensure appropriate coverage of a person's medical expenses. TPOC submission is mandatory for those already enrolled in Medicare based on age or Social Security Disability Insurance (SSDI) when the settlement is $25,000 or more.
Additionally, TPOCs are necessary if the person is not currently enrolled in Medicare but will qualify for the program within 30 months of the settlement date, and the settlement amount is $250,000 or more. Besides workers' comp, a person must report settlements from liability or no-fault insurance claims too.
Frequently Asked Questions
For questions about Medicare, contact Medicare at 800-MEDICARE (800-633-4227, TTY 877-486-2048). A live chat is available on Medicare.gov during select hours. If you have questions about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A WCMSA is voluntary. To set one up, the workers' compensation settlement must be over $25,000 or over $250,000 within 30 months if eligible for Medicare. Misusing funds in a WCMSA is prohibited, and doing so can lead to denials and reimbursement obligations.
"Learn More: Understanding Medicare Set-Asides"
Takeaway
Workers' compensation is essential for job-related injuries or illnesses, and understanding its relationship with Medicare is crucial to avoid future claim rejections and reimbursement obligations.
It's essential to inform Medicare about workers' compensation arrangements to avoid unnecessary complications.
Medicare Resources
For further guidance on navigating the complex world of medical insurance, visit our Medicare hub.
The Medicare Set-Aside Arrangement (WCMSA) is a voluntary agreement that can be established when a workers' compensation settlement exceeds $25,000 or $250,000 within 30 months if eligible for Medicare.
Misusing funds in a WCMSA is prohibited and can lead to claim denials and reimbursement obligations.
In cases where someone enrolled in Medicare or approaching eligibility experiences a work-related injury or illness, Medicare's secondary payer policy mandates that workers' compensation must cover any treatment related to the injury before Medicare steps in.
Health systems, nutritionists, and providers offering therapies and treatments, health-and-wellness advice, and other uncategorized services must be aware of the potential impact on Medicare coverage when providing care to workers who have received workers' compensation settlements.
