Understanding Intersection of Workers' Compensation and Medicare: Essential Facts
Revised Article:
Navigating worker's comp and Medicare ain't a walk in the park. Neglecting to inform Medicare about your workman's comp setup could lead to claim rejections and reimbursing Medicare down the line.
Worker's compensation serves as insurance for employees who've suffered job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor handles this benefit, catering to federal employees, their families, and select entities.
If you're already on Medicare or about to join, it's crucial to grasp how your worker's comp benefits might intertwine with Medicare's coverage of your medical bills. This is key to avoiding complications with work-related medical costs.
How does a worker's comp settlement affect Medicare?
Under Medicare's secondary payer policy, worker's comp must get top billing for any treatment linked to a work-related injury.
In situations where immediate medical costs crop up before you pocket your worker's comp settlement, Medicare might foot the bill first, then initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To avoid such recovery hassles, the Centers for Medicare & Medicaid Services (CMS) generally keeps an eye on the amount you receive from worker's comp for injury or illness-related medical care.
In some cases, Medicare might request a worker's comp Medicare Set-Aside Arrangement (WCMSA) for these funds. Medicare will only cover your care once all the money in the WCMSA has been spent.
What settlements should be reported to Medicare?
Worker's comp must submit a Total Payment Obligation to the Claimant (TPOC) to CMS if you're already on Medicare or due to join within 30 months based on age, or are collecting Social Security Disability Insurance. This represents the total sum owed to you (or on your behalf).
Moreover, you're required to report if your worker's comp settlement is $25,000 or more. If you're not yet on Medicare but will be within 30 months of the settlement date, and the settlement amount is $250,000 or more, you must also file a TPOC.
Similarly, reporting is necessary if you file a liability or no-fault insurance claim.
FAQ
You can reach out to Medicare by dialing 800-MEDICARE (800-633-4227, TTY 877-486-2048). During specific hours, you can also chat with them on Medicare.gov. For inquiries about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
A Medicare Set-Aside is optional. However, if you wish to set one up, your worker's comp settlement must exceed $25,000. Otherwise, if you're eligible for Medicare within 30 months, the settlement must be over $250,000.
Misusing the money in a Medicare Set-Aside Arrangement (WCMSA) is off-limits. Violating this rule could lead to claim denials and reimbursing Medicare later on.
"Learn More: Understanding Medicare Set-Asides"
Takeaway
Worker's compensation caters to job-related injuries or illnesses for federal employees and select groups.
If you're on Medicare or approaching it, understanding how worker's comp might affect your coverage is essential to bypass medical expense troubles.
Ensuring proper communication with Medicare about your worker's comp setup saves you from potential claim rejections and reimbursement obligations later on.
Medicare Resources
For more guidance on navigating the tricky world of medical insurance, dip into our Medicare Hub.
- Medicare's secondary payer policy dictates that in cases of work-related injuries, worker's compensation must cover the treatment costs before Medicare.
- If a worker's compensation settlement exceeds $25,000, it needs to be reported to the Centers for Medicare & Medicaid Services (CMS) irrespective of the recipient's Medicare status.
- In situations where Medicare sets up a Medicare Set-Aside Arrangement (WCMSA), it will only cover the claimant's care after the WCMSA funds have been expended.
- The Office of Workers' Compensation Programs (OWCP) caters to federal employees, their families, and select entities by providing insurance for job-related injuries or illnesses, making it an essential part of the healthsystems related to health-and-wellness, therapies-and-treatments, and nutrition.
