Medicare and Workers' Compensation Interaction: Essential Insights Explained
Living with a Workers' Comp Claim and Medicare? Here's What You Need to Know
Navigating workers' compensation and Medicare can be tricky, but understanding the process is crucial to avoid claim denials and reimbursement obligations.
Workers' compensation serves as insurance for employees dealing with job-related injuries or illnesses, overseen by the Office of Workers' Compensation Programs under the Department of Labor. Federal employees, their families, and select entities are eligible for this benefit.
If you're already enrolled in Medicare or anticipate entering the program soon, it's vital to comprehend how your workers' compensation benefits may influence Medicare's coverage of medical claims related to your workplace injuries or illnesses. This helps avoid costly medical complications.
Workers' Comp Settlements and Medicare: Explained
Remember, under Medicare's secondary payer policy, workers' compensation must first pay for treatments related to work-related injuries. However, if initial medical expenses arise before the workers' compensation settlement, Medicare might pay these costs and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To prevent a recovery process and ensure Medicare only covers treatments after the workers' compensation funds for injury-related medical care have been exhausted, the Centers for Medicare & Medicaid Services (CMS) monitors the settlement amount. In some cases, CMS may demand a workers' compensation Medicare set-aside arrangement (WCMSA).
Reportable Workers' Comp Settlements
When it comes to reporting workers' compensation settlements, there are specific thresholds to consider. The payment must be reported to CMS when it exceeds $25,000 if the person is already enrolled in Medicare based on age or Social Security Disability Insurance (SSDI).
Additionally, if the person is not enrolled in Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more, a report to CMS is necessary. Workers' compensation settlements involving filing for liability or no-fault insurance claims should also be reported.
Frequently Asked Questions
For any questions about workers' compensation and Medicare, you can contact Medicare directly at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or by visiting Medicare.gov during specific hours for live chat support. If you have inquiries about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
Understanding Medicare Set-Asides (WCMSAs)
While a WCMSA is voluntary, it's strongly encouraged if your settlement exceeds the $25,000 threshold (or $250,000 if you're eligible for Medicare within 30 months). Misusing WCMSA funds for purposes other than the designated one may lead to claim denials and reimbursement obligations.
Learn more about Medicare set-asides: What to know about Medicare set-aside
Takeaway
By knowing the rules governing workers' compensation and Medicare, federal employees and eligible groups can take necessary steps to avoid future complications with medical expenses related to work-related injuries or illnesses. Proper reporting and, when needed, setting up a workers' compensation Medicare set-aside arrangement can safeguard your interests and prevent claim denials and reimbursement obligations.
Medicare resources
For more resources to navigate the complexities of medical insurance, visit our Medicare hub.
- If you have questions about workers' compensation and Medicare, you can reach Medicare directly at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or visit Medicare.gov for live chat support during specific hours.
- For inquiries about the Medicare recovery process, contact the Benefits Coordination & Recovery Center (BCRC) at 855-798-2627 (TTY 855-797-2627).
- When reporting workers' compensation settlements, a report to CMS is necessary if the payment exceeds $25,000 for those already enrolled in Medicare, or $250,000 for those qualifying within 30 months of the settlement date.
- To prevent a recovery process and ensure Medicare covers treatments after workers' compensation funds for injury-related medical care have been exhausted, the Centers for Medicare & Medicaid Services (CMS) may demand a workers' compensation Medicare set-aside arrangement (WCMSA) if the settlement exceeds the specified thresholds.
