Medicare and Workers' Compensation Interactions: Key Facts to Understand
Navigating the world of workers' compensation and Medicare is essential for anyone who might find themselves in a work-related injury scenario, especially federal employees and certain other groups.
Here's the lowdown on how workers' compensation (WC) can affect your Medicare coverage:
- Primary Payer Policy: Under Medicare's secondary payer policy, WC must cover any treatment you receive for a work-related injury before Medicare chips in.
- Immediate Expenses: If you incur immediate medical expenses before receiving your WC settlement, Medicare may pay first and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To avoid this, the Centers for Medicare & Medicaid Services (CMS) usually monitors the amount you receive from WC for your injury-related medical care and might ask for a WC Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover the care after all the money in the WCMSA has been exhausted.
So, what settlements need to be reported to Medicare?
- Total Payment Obligation to the Claimant (TPOC) submission is vital if you're already enrolled in Medicare based on your age or based on receiving Social Security Disability Insurance, and the settlement is $25,000 or more.
- TPOCs are also necessary if you're not currently enrolled in Medicare but will qualify for the program within 30 months of the settlement date, and the settlement amount is $250,000 or more.
In addition to WC, you must report to Medicare if you file a liability or no-fault insurance claim.
Frequently Asked Questions:
- You can contact Medicare with any question by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is also available on Medicare.gov. If you have questions about the Medicare recovery process, you can contact the BCRC at 855-798-2627 (TTY 855-797-2627).
What's more, a Medicare set-aside is voluntary, but if you wish to set one up, your WC settlement must be over $25,000. Alternatively, it must be over $250,000 if you're eligible for Medicare within 30 months.
Keep in mind that misusing the money in a Medicare set-aside arrangement can lead to claim denials and having to reimburse Medicare.
To sum up, if your WC settlement is over $25,000 (or any amount if you're a current Medicare beneficiary), the insurer/self-insured entity will handle the reporting and WCMSA process as required by law. The 30-month window is used to determine if you're reasonably expected to be a beneficiary, which may require a WCMSA and reporting. The actual reporting is done quarterly by the insurer, not within 30 months of the settlement date.
- Recipients of Medicare based on age or Social Security Disability Insurance should report a workers' compensation settlement of $25,000 or more to the Centers for Medicare & Medicaid Services (CMS) according to the Primary Payer Policy.
- If a workers' compensation settlement is $250,000 or more and the recipient is not currently enrolled in Medicare but will qualify within 30 months, the TPOC submission is mandatory.
- Apart from workers' compensation, liability or no-fault insurance claims also need to be reported to Medicare.
