Medicare and Workers' Compensation: Essential Information for Awareness
Navigating Workers' Comp and Medicare: A Guide for Federal Employees
Getting the lowdown on Medicare and workers' comp is essential for federal workers, since their jobs can sometimes result in injuries or illnesses. This guide serves to explain the ins and outs of work-related benefits and how they interact with Medicare.
The Workers' Comp Scene: Who's in Charge
The Office of Workers' Compensation Programs (OWCP), tucked under the umbrella of the Department of Labor, is responsible for providing workers' comp benefits to federal employees, their families, and selected other entities.
Medicare's Role in Workers' Comp Cases
People already enrolled in Medicare, those IMs about to qualify, or those with workers' comp claims need to comprehend how these benefits might affect Medicare coverage of medical claims. Proper understanding helps minimize complications concerning medical costs associated with work-related injuries and illnesses.
How Workers' Comp Settlements Impact Medicare
Under Medicare's secondary payer policy, workers' comp must be the primary insurer for injured employees' medical treatment. If upfront medical expenses crop up before the employee receives their compensation settlement, Medicare could cover the costs first and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To avoid a recovery process and secure the allocated funds, the Centers for Medicare & Medicaid Services (CMS) monitors the amount an employee receives from workers' comp for their injury- or illness-related medical care. In some cases, Medicare will ask for a workers' comp Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover treatment after all the money in the WCMSA has been depleted.
Settlements to Report to Medicare
In order to ensure Medicare covers appropriate medical expenses for workers and their ensuing injuries or illnesses, workers' comp needs to submit a total payment obligation to the claimant (TPOC) to CMS. A TPOC is necessary if the employee is already enrolled in Medicare based on their age or SSDI, and the settlement is $25,000 or more.
Additionally, if the employee isn't 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 necessary. Settlements involving liability or no-fault insurance claims must also be reported to Medicare.
Frequently Asked Questions
for inquiries or questions about Medicare, dial 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is also 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 Medicare set-aside is voluntary. If a beneficiary prefers to organize an MSA, their workers' comp settlement must surpass $25,000, or $250,000 if the beneficiary will become eligible within 30 months.
Using the funds in a Medicare set-aside arrangement for purposes other than the designated one can result in claim denials and the need to reimburse Medicare.
"Learn More: What to Know about Medicare Set-Asides
Takeaway
Workers' compensation offers insurance protection for federal employees and select groups, covering job-related injuries and illnesses.
For individuals enrolled in Medicare or those close to qualifying, it's crucial to grasp how workers' comp might impact Medicare coverage to prevent complications regarding medical expenses.
Notifying Medicare about workers' comp agreements ensures future claim approvals and assuages reimbursement obligations.
Medicare Resources
For more resources to help you navigate the intricate world of medical insurance, head over to our Medicare hub.
- People already enrolled in Medicare, those close to qualifying, or those with workers' comp claims need to understand how these benefits might affect Medicare coverage of medical claims, to prevent complications concerning medical costs associated with work-related injuries and illnesses.
- Under Medicare's secondary payer policy, workers' comp must be the primary insurer for injured employees' medical treatment. If upfront medical expenses crop up before the employee receives their compensation settlement, Medicare could cover the costs first and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
- In order to ensure Medicare covers appropriate medical expenses for workers and their ensuing injuries or illnesses, workers' comp needs to submit a total payment obligation to the claimant (TPOC) to CMS, specifically when the employee is already enrolled in Medicare based on their age or SSDI, and the settlement is $25,000 or more, or if the employee isn't currently enrolled in Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more.
- A Medicare set-aside is voluntary, but if a beneficiary prefers to organize an MSA, their workers' comp settlement must surpass $25,000, or $250,000 if the beneficiary will become eligible within 30 months. Using the funds in a Medicare set-aside arrangement for purposes other than the designated one can result in claim denials and the need to reimburse Medicare.
