Medicare and Workers' Compensation: Key Facts to Understand
Navigating the crossover between workers' compensation and Medicare is vital to avoid claim denials and hefty reimbursements. Here's a lowdown on how it all works.
Workers' comp is insurance that safeguards employees from injuries or illnesses caused directly by their jobs. Managed by the Office of Workers' Compensation Programs under the Department of Labor, it covers federal employees, their families, and certain other entities.
If you're on Medicare or planning to join soon, it's crucial to understand how workers' comp might impact Medicare's coverage of your medical claims. Proactive action can prevent costly wrangles with medical bills stemming from workplace injuries.
What's a Workers' Comp Settlement Got to Do with Medicare?
Under Medicare's secondary payer policy, workers' comp must cover any treatment for work-related injuries before Medicare kicks in. In case of immediate medical expenses before the settlement, Medicare may pay upfront and instigate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To avoid recovery processes, the Centers for Medicare & Medicaid Services (CMS) generally keeps tabs on the money a person receives from workers' comp for injury or illness-related medical care. In some cases, Medicare may even seek a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare won't foot the bill until the WCMSA funds are used up.
Which Settlements Need to Be Reported to Medicare?
Workers' comp must submit a Total Payment Obligation to the Claimant (TPOC) to CMS if:
- You're already on Medicare due to age or Social Security Disability Insurance, and the settlement is $25,000 or more.
- You're not on Medicare but will be within 30 months of the settlement date, and the settlement amount is $250,000 or more.
Additionally, if you file a liability or no-fault insurance claim, you'll also need to report this to Medicare.
Frequently Asked Questions
You can reach out to Medicare via phone at 800-MEDICARE (TTY 877-486-2048) or through live chat on Medicare.gov during certain hours. For queries 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 want one, your workers' comp settlement must exceed $25,000 (or $250,000 within 30 months if eligible for Medicare soon).
Using the money in a Medicare set-aside arrangement for anything other than its intended purpose can lead to claim denials and reimbursement obligations.
Learn more: Medicare Set-Asides
Takeaway
Workers' compensation ensures workplace injuries or illnesses are covered for federal employees and certain groups. Understanding how workers' comp affects Medicare coverage can prevent issues with medical expenses and claim rejections.
Stay informed by visiting our Medicare hub to navigate the intricate world of medical insurance [Medicare Hub].
- Workers' compensation insurance, managed by the Office of Workers' Compensation Programs under the Department of Labor, is responsible for covering injuries or illnesses caused directly by a job for federal employees and certain entities.
- When navigating Medicare, it's essential to understand that workers' comp must cover any treatment for work-related injuries before Medicare kicks in, to avoid costly disputes with medical bills resulting from workplace injuries.
- Under Medicare's secondary payer policy, Medicare may pay upfront for immediate medical expenses before the workers' comp settlement, and subsequently endeavor a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
- To avoid recovery processes, the Centers for Medicare & Medicaid Services (CMS) keeps track of the money a person receives from workers' comp for injury or illness-related medical care, and may even set up a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds.
- Workers' comp must report a Total Payment Obligation to the Claimant (TPOC) to CMS if the settlement exceeds $25,000 for those already on Medicare, or $250,000 for those not yet on Medicare but eligible within 30 months.
