Medicare and Workers' Compensation Interactions: Key Points to Understand
Navigating the waters of Medicare when it comes to workers' compensation can be a tricky business. Neglecting to notify Medicare about workers' comp arrangements could lead to claim denials and a hefty bill for you to cover.
Workers' compensation serves as an insurance policy for those who've encountered injuries or illnesses at their job. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor manages this benefit for federal employees, their families, and other entities.
If you're enrolled in Medicare or are about to qualify, it's crucial to understand how your workers' comp benefits might impact Medicare's coverage of your medical claims. This knowledge can help prevent complications with medical costs for work-related injuries or illnesses.
Living with a Workers' Comp Settlement and Medicare
Under Medicare's secondary payer policy, workers' compensation should cover any treatment related to work-related injuries before Medicare chimes in.
In cases where immediate medical expenses arise before the workers' comp settlement, Medicare may pay first and start a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To avoid this process and keep your money in your pockets, it's best to let the Centers for Medicare & Medicaid Services (CMS) monitor the amount you receive from workers' comp for your injury-related medical care. In some instances, Medicare may ask for a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Once the WCMSA funds are exhausted, Medicare will cover the remaining medical costs.
When to Report Settlements to Medicare
Workers' comp needs to submit a Total Payment Obligation to the Claimant (TPOC) to CMS if the settlement is $25,000 or more for those already enrolled in Medicare, based on age or Social Security Disability Insurance. For those not yet enrolled in Medicare but will qualify within 30 months of the settlement date, the requirement kicks in when the settlement surpasses $250,000. Additionally, if you file a liability or no-fault insurance claim, you should also report it to Medicare.
FAQs
Feel free to reach out to Medicare with any questions by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or via live chat on Medicare.gov during certain hours. If you have concerns about the Medicare recovery process, you can contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A WCMSA is voluntary, but if you opt for one, your workers' comp settlement should exceed $25,000 or $250,000 if you're eligible for Medicare within 30 months after the settlement date. It's also prohibited to use the money in a WCMSA for anything other than the intended purpose, or else you risk claim denials and reimbursement obligations.
So, remember, when it comes to workers' comp and Medicare, knowledge is power. Be sure to communicate with both parties, understand the rules, and make informed decisions about your settlement to avoid any potential complications down the line. For more resources on managing medical insurance, check out our Medicare hub!
- Navigating Medicare in relation to workers' compensation can be complex, as failing to notify Medicare about workers' comp arrangements may lead to claim denials and substantial financial burden for you.
- The Office of Workers' Compensation Programs (OWCP) under the Department of Labor manages workers' compensation benefits for federal employees, their families, and other entities.
- Under Medicare's secondary payer policy, workers' compensation should cover treatment related to work-related injuries before Medicare steps in, reducing potential complications with medical costs.
- If your workers' comp settlement is $25,000 or more, and you're already enrolled in Medicare or will qualify within 30 months, the workers' comp provider must submit a Total Payment Obligation to the Claimant (TPOC) to Medicare.
- Therapies and treatments, nutrition, and other aspects of health-and-wellness are crucial factors in recovery from work-related injuries or illnesses, and understanding how workers' comp and Medicare interact can help ensure you receive the necessary coverage.
- The Centers for Medicare & Medicaid Services (CMS) and the Benefits Coordination & Recovery Center (BCRC) can provide assistance for any questions or concerns regarding the Medicare recovery process.
