Medicare and Workers' Compensation: Key Points to Understand
Essential Information for Workers' Compensation Claimants: Notifying Medicare is Crucial to Prevent Claim Denials
Workers' compensation, an insurance policy for employees who sustain job-related injuries or illnesses, is managed by the Office of Workers' Compensation Programs (OWCP) under the Department of Labor. This coverage extends to federal workers, their families, and certain other entities.
Individuals who are currently enrolled in Medicare or are approaching eligibility should be aware of how their workers' compensation benefits might impact Medicare's coverage of their medical claims. By understanding this relationship, they can prevent complications and ensure medical costs for work-related injuries or illnesses are properly managed.
Understanding the Impact of Workers' Compensation Settlements on Medicare
Under Medicare's secondary payer policy, workers' compensation is responsible for paying for any treatment related to a work-related injury. However, if immediate medical expenses arise prior to the individual receiving their workers' compensation settlement, Medicare may pay first and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To avoid this process, the Centers for Medicare & Medicaid Services (CMS) monitors the amount a claimant receives from workers' compensation for injury or illness-related medical care.
In some cases, Medicare may request the establishment of a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) for these funds. Medicare will only cover care after all the money in the WCMSA has been exhausted.
Reporting Workers' Compensation Settlements to Medicare
Workers' compensation must report a total payment obligation to the claimant (TPOC) to CMS to ensure Medicare covers the appropriate portion of a person's medical expenses. This is necessary for claimants who are already enrolled in Medicare based on their age or Social Security Disability Insurance, or if the settlement is $25,000 or more.
TPOCs are also required 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. Additionally, a person must report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
For questions related to Medicare coverage, individuals can 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. Questions about the Medicare recovery process can be directed to the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary, but it must be established if the worker's compensation settlement is over $25,000 or $250,000 if the individual is eligible for Medicare within 30 months. Using the money in a Medicare set-aside arrangement for purposes other than that designated is prohibited and can lead to claim denials and the need to reimburse Medicare.
In summary, understanding the interaction between workers' compensation and Medicare is crucial to prevent claim denials and avoid reimbursement obligations. Proper reporting of workers' compensation agreements is essential for maintaining Medicare coverage and navigating the complexities of medical insurance.
- The Centers for Medicare & Medicaid Services (CMS) monitors the amount a claimant receives from workers' compensation for injury or illness-related medical care, which impacts Medicare's coverage of medical claims.
- Workers' compensation must report a total payment obligation to the claimant (TPOC) to CMS if the settlement amount is $25,000 or more, or 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.
- A Medicare set-aside is voluntary, but it must be established if the worker's compensation settlement is over $25,000 or $250,000 if the individual is eligible for Medicare within 30 months, using the money in a Medicare set-aside arrangement for purposes other than that designated is prohibited and can lead to claim denials and the need to reimburse Medicare.
- In the realm of health-and-wellness, nutrition, therapies-and-treatments, and science, it's essential for workers' compensation claimants, Medicare recipients, and healthcare providers to collaborate and ensure proper reporting, as misunderstanding the relationship between workers' compensation and Medicare can result in financial complications and claim denials.
