naviguing the intersection of workers' compensation and Medicare: key facts to understand
Vital Information for Medicare Beneficiaries Regarding Workers' Compensation
Beneficiaries of Medicare should be aware of the implications of workers' compensation arrangements on their insurance coverage to prevent potential claim denials and reimbursement obligations.
Workers' compensation is an insurance program designed to provide benefits for employees who have suffered injuries or illnesses directly related to their job. The Office of Workers' Compensation Programs (OWCP), under the Department of Labor, administers this program for federal workers, their families, and other eligible entities.
When a beneficiary is enrolled in Medicare or soon to be eligible, it is essential to understand how workers' compensation may impact Medicare's coverage of medical claims associated with workplace injuries or illnesses. This understanding helps to avoid complications with medical expenses resulting from work-related incidents.
Understanding Workers' Compensation Settlements and Medicare
Under Medicare's Secondary Payer policy, workers' compensation should serve as the primary payer for any treatment related to a work-related injury. However, if immediate medical expenses arise before a workers' compensation settlement, Medicare may cover the initial costs and subsequently initiate a recovery process overseen by the Benefits Coordination & Recovery Center (BCRC).
To avoid a recovery process, the Centers for Medicare & Medicaid Services (CMS) typically monitors the amount received 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 the WCMSA funds have been exhausted.
Reporting Workers' Compensation Settlements to Medicare
Workers' compensation is responsible for reporting certain settlements to Medicare to ensure appropriate Medicare coverage for the beneficiary's medical expenses. This involves submitting a total payment obligation to the claimant (TPOC) to CMS if the settlement exceeds specific thresholds.
- If the settlement is $25,000 or more for a person already enrolled in Medicare, or for a person who will soon qualify based on age or Social Security Disability Insurance (SSDI), the TPOC must be reported to Medicare.
- For individuals not currently enrolled in Medicare but who will qualify within 30 months of the settlement date and have a settlement amount of $250,000 or more, the TPOC also needs to be reported.
In addition to workers' comp, the beneficiary must report to Medicare if they file a liability or no-fault insurance claim.
Frequently Asked Questions
A beneficiary can contact Medicare with any question by calling 800-MEDICARE (800-633-4227, TTY 877-486-2048) or during certain hours, initiate a live chat on Medicare.gov. Questions about the Medicare recovery process may be directed to the Benefits Coordination & Recovery Center (BCRC) at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is voluntary, but if a Medicare beneficiary wants to set one up, their workers' compensation settlement must exceed $25,000 or $250,000 depending on their eligibility for Medicare. Misuse of funds in a Medicare set-aside arrangement can lead to claim denials and reimbursement obligations.
Key Takeaways
Workers' compensation offers insurance protection for job-related injuries or illnesses for federal employees and certain other groups.
To prevent issues with medical expenses, those enrolled in Medicare or soon to be eligible should educate themselves on the relationship between workers' compensation and Medicare coverage.
Prompt reporting of workers' compensation agreements to Medicare is crucial to avoiding future claim rejections and reimbursement obligations.
For additional resources on navigating the complex world of medical insurance, visit our Medicare hub.
- Under Medicare's Secondary Payer policy, workers' compensation is expected to serve as the primary payer for any treatment related to a work-related injury, but Medicare may cover initial costs before a workers' compensation settlement.
- In certain cases, Medicare may request the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for funds received from workers' compensation related to injury or illness-related medical care.
- When a workers' compensation settlement exceeds specific thresholds, it is the responsibility of workers' compensation to report this information to Medicare to ensure appropriate Medicare coverage for the beneficiary's medical expenses.
