Medicare and Workers' Compensation: Essential Facts You Need to Understand
Working with Workers' Compensation and Medicare: A Comprehensive Guide
Never miss a beat when handling workers' compensation claims and Medicare benefits. Here's a break-down of how to navigate this complex relationship effectively.
The Nitty-Gritty of Workers' Compensation and Medicare
Workers' compensation is an essential safety net for federal employees and eligible entities, providing coverage for injuries and illnesses directly related to their jobs. Managed by the Office of Workers' Compensation Programs (OWCP), it's crucial for those enrolled or approaching Medicare to understand its intersection with their medical care.
When Workers' Compensation and Medicare Collide
Under Medicare's secondary payer policy, workers' compensation is expected to cover primary expenses for treatment resulting from a work-related injury. However, in cases where immediate medical bills arise prior to the workers' compensation settlement, Medicare may step in as the initial payer. To prevent a recovery process managed by the Benefits Coordination & Recovery Center (BCRC), the Centers for Medicare & Medicaid Services (CMS) often monitors the amount received in your workers' compensation settlement for injury- or illness-related medical care. In some instances, Medicare may even request the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Post-exhaustion of the WCMSA, Medicare will cover remaining costs.
Setting the Record Straight
Workers' compensation settlements totaling $25,000 or more must be reported to Medicare if the individual is currently enrolled or will soon qualify based on age or Social Security Disability Insurance eligibility. If the recipient is not enrolled in Medicare but will do so within 30 months of the settlement date, a reporting requirement applies to settlements of $250,000 or more. Additionally, reporting is also necessary for liability or no-fault insurance claims.
Frequently Asked Questions
For any inquiries regarding workers' compensation and Medicare, don't hesitate to contact Medicare at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or via the live chat available on Medicare.gov during specific hours. If you have concerns about the Medicare recovery process, reach out to the BCRC at 855-798-2627 (TTY 855-797-2627).
Your Questions, Answered
- A Medicare set-aside is voluntary, but those contemplating one must have a workers' compensation settlement above $25,000 or $250,000 within 30 months.
- Misusing funds from a Medicare set-aside arrangement can lead to claim denials and reimbursement obligations.
Key Takeaways
- Stay informed on how workers' compensation may impact your Medicare coverage to avoid complications with medical expenses.
- Report workers' compensation agreements to Medicare to avoid future claim rejections and reimbursement obligations.
Additional ResourcesCheck out our Medicare hub for more insights and guidance on navigating the complex world of medical insurance.
Enrichment Insights
- Reporting Requirements: As of April 4, 2025, Medicare beneficiaries and their representatives must report all workers' compensation settlements to CMS through Section 111 reporting, including cases where the Medicare Set-Aside (MSA) amount is $0 or settlements below $25,000[1][2][4].
- Submission Process: Reporting is typically handled by insurance carriers, self-insured entities, or third-party administrators, who submit settlement details to CMS[4].
- Thresholds for Submission: No specific thresholds for submission based on the settlement amount; all settlements involving Medicare beneficiaries must be reported, regardless of the amount[1][4].
- Key Steps for Beneficiaries:
- Document all settlement details, including any allocation for future medical expenses.
- Seek assistance from entities handling workers' compensation claims for the reporting process.
- Ensure the reporting entity is aware of and complies with CMS regulations.
- Important Dates:
- April 4, 2025: CMS began requiring Section 111 reporting for workers' compensation MSAs for TPOC dates after this date[5].
- April 7, 2025: Amended review requests can be submitted at any time after a WCMSA case is approved, eliminating the one-year waiting period[2][5].
- July 17, 2025: CMS will no longer accept or review WCMSA proposals with a zero-dollar allocation[2].
- The Office of Workers' Compensation Programs (OWCP) manages workers' compensation, which provides coverage for job-related injuries and illnesses, especially for those approaching or enrolled in Medicare.
- Medicare's secondary payer policy dictates that workers' compensation should cover primary expenses for treatments resulting from work-related injuries, but in certain cases, Medicare may pay initial medical bills prior to the workers' compensation settlement.
- To prevent recovery process interference by the Benefits Coordination & Recovery Center (BCRC), the Centers for Medicare & Medicaid Services (CMS) often monitors the workers' compensation settlement amounts for injury- or illness-related medical care.
- In some instances, Medicare may request the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds, post-exhaustion of which, Medicare will cover remaining costs.
- Workers' compensation settlements totaling $25,000 or more must be reported to Medicare if the individual is currently enrolled or will soon qualify based on age or Social Security Disability Insurance eligibility.
- For those not currently enrolled in Medicare but will do so within 30 months of the settlement date, a reporting requirement applies to settlements of $250,000 or more, as well as for liability or no-fault insurance claims.
- Reporting requirements for workers' compensation settlements will be more stringent as of April 4, 2025, with Medicare beneficiaries and their representatives required to report all workers' compensation settlements to CMS through Section 111 reporting.
