Medicare and Workers' Compensation: Crucial Information You Should Be Aware Of
Important Reminder: Properly Notifying Medicare about a Workers' Compensation Settlement is Crucial
Workers' compensation is an insurance program that offers financial assistance to employees who have incurred work-related injuries or illnesses. This program falls under the jurisdiction of the Office of Workers' Compensation Programs (OWCP) within the Department of Labor, and it covers federal employees, their families, and certain other entities.
Enrollees in Medicare or those approaching eligibility for the insurance program must be aware of how a workers' compensation settlement may impact Medicare's coverage for healthcare claims related to work injuries or illnesses. This understanding is essential for avoiding complications with medical expenses.
Understanding the Impact of a Workers' Compensation Settlement on Medicare
Medicare, as secondary payer, typically covers medical treatments for work-related injuries only after workers' compensation has been exhausted. However, in cases where immediate medical costs arise before the settlement is received, Medicare might initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To prevent such a recovery process and ensure seamless coverage, the Centers for Medicare & Medicaid Services (CMS) monitors the amount a person receives from workers' compensation for injury- or illness-related medical care. In some instances, Medicare may require a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) to be established, ensuring coverage only after the WCMSA funds have been utilized.
Reportable Settlements and Establishing a WCMSA
Workers' compensation must submit the Total Payment Obligation to the Claimant (TPOC) to Medicare to guarantee proper coverage for the recipients' medical expenses. Submission of this TPOC is mandatory when:
- The person is already enrolled in Medicare on account of age or Social Security Disability Insurance, and the settlement exceeds $25,000.
- The person is not currently enrolled in Medicare but is expected to qualify for the program within 30 months of the settlement date, and the settlement amount is $250,000 or more.
Additionally, enrolees must report to Medicare in case of filing a liability or no-fault insurance claim.
Frequently Asked Questions
Medicare can be contacted by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or through a live chat on Medicare.gov during certain hours. Inquiries regarding the Medicare recovery process can be directed to the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is optional, but if a beneficiary chooses to establish one, their workers' compensation settlement must be over $25,000. This threshold applies whether the person is eligible for Medicare within 30 months or not. Misusing the money in a Medicare set-aside arrangement can lead to claim denials and reimbursement obligations.
Takeaway
Workers' compensation covers job-related injuries or illnesses for federal employees as well as certain other groups. Enrollees in Medicare or those about to become eligible should educate themselves on the potential impact of workers' compensation on their coverage to avoid any medical expense issues.
To avoid future claim rejections and potential reimbursement obligations, it is crucial to notify Medicare about workers' compensation agreements appropriately.
- Medicare, as a secondary payer, typically covers medical treatments for work-related injuries only after workers' compensation has been exhausted.
- Understanding the impact of a Workers' Compensation settlement on Medicare is essential to prevent complications with medical expenses.
- In instances where a person receives a settlement from workers' compensation for injury- or illness-related medical care, Medicare may require a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) to be established.
- Reportable settlements must be submitted to Medicare to guarantee proper coverage for medical expenses, either when the person is already enrolled in Medicare or is expected to qualify within 30 months.
- Enrollees must report to Medicare in case of filing a liability or no-fault insurance claim.
