Navigating Medicare and Workers' Compensation: All You Need to Know
Medicare and workers' compensation: Essential information
Staying informed about how workers' compensation affects your Medicare coverage is crucial for avoiding complications with medical costs, especially for workplace injuries. Here's what you should know:
Who's Covered by Workers' Compensation?
Workers' compensation insurance offers a safety net for employees who sustain job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor handles these benefits, which apply to federal employees, their families, and other entities.
Workers' Compensation and Medicare: Staying Ahead
Medicare operates under a secondary payer policy, meaning workers' compensation must be the primary payer for work-related injury treatments. However, if immediate expenses occur before the workers' compensation settlement, Medicare might cover the initial costs, and a recovery process will be initiated by the Benefits Coordination & Recovery Center (BCRC).
To avoid a recovery process, the Centers for Medicare & Medicaid Services (CMS) often keeps track of the amount received from workers' compensation for injury-related medical care. In some cases, Medicare may establish a workers' compensation Medicare set-aside arrangement (WCMSA) for managing these funds. Medicare will only fund treatment after the WCMSA has been exhausted.
Reportable Settlements to Medicare
To ensure Medicare caters to the appropriate portion of a person's medical expenses, workers' compensation is required to submit a total payment obligation to the claimant (TPOC) to CMS. This is necessary if a person is already enrolled in Medicare or will soon qualify within 30 months, and the settlement is $25,000 (for the former) or $250,000 (for the latter). Additionally, if a person files a liability or no-fault insurance claim, it must also be reported.
FAQs
- How to contact Medicare? You can reach out to Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is available on Medicare.gov. For questions about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
- Is a Medicare set-aside mandatory? No, it's voluntary. However, if you wish to set one up, your workers' compensation settlement must be over $25,000 or $250,000 if you're eligible for Medicare within 30 months.
- Can Medicare set-aside funds be misused? Yes. Misusing the funds can lead to claim denials and reimbursement obligations to Medicare.
Takeaway
No matter if you're currently enrolled in Medicare or will soon be eligible, understanding how workers' compensation affects your Medicare coverage can help you avoid claim rejections and reimbursement obligations. Inform Medicare about your workers' compensation agreements to ensure seamless insurance coverage for work-related injuries and illnesses.
- The Office of Workers' Compensation Programs (OWCP) handles benefits for federal employees, their families, and other entities who sustain job-related injuries or illnesses.
- Medicare operates under a secondary payer policy, meaning workers' compensation must be the primary payer for work-related injury treatments.
- If a person is already enrolled in Medicare or will soon qualify within 30 months, and their workers' compensation settlement exceeds $25,000 or $250,000, they are required to submit a total payment obligation to the claimant (TPOC) to the Centers for Medicare & Medicaid Services (CMS).
- Medicare may establish a workers' compensation Medicare set-aside arrangement (WCMSA) for managing funds received from workers' compensation for injury-related medical care, ensuring that Medicare will only fund treatment after the WCMSA has been exhausted.
- Failing to report and manage workers' compensation settlements properly can lead to claim denials and reimbursement obligations to Medicare, which could have financial and health system implications for individuals and their healthcare providers.
- Proper understanding and navigation of the Medicare and workers' compensation systems can help individuals avoid complications, claim rejections, and reimbursement obligations.
- In addition to workers' compensation and Medicare, individuals should also be aware of the role of health systems, health-and-wellness, therapies-and-treatments, nutrition, and finance in managing work-related injuries and illnesses, as well as the impact of business practices on the overall system.
