Medicare and Workers' Compensation: Key Points for Understanding
Chatting about Workers' Compensation and Medicare:
Working Comp means business, even when it comes to Medicare
It's essential to keep Medicare in the loop when handling workers' compensation cases. Why? Because if you don't, you might find yourself dealing with claim denials and the need to reimburse Medicare.
Workers' comp 101
Workers' compensation is insurance for individuals who've sustained job-related injuries or illnesses. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor oversees this benefit, which extends to federal employees, their families, and eligible entities.
Workers' comp and Medicare: step by step
When it comes to Medicare's secondary payer policy, workers' compensation must cover treatment for work-related injuries first. However, if emergency medical expenses arise before the person receives their workers' compensation settlement, Medicare might pay upfront. In such cases, Medicare initiates a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To prevent this recovery process and maintain transparency, the Centers for Medicare & Medicaid Services (CMS) usually keeps track of the amount a person receives from workers' compensation for their injury or illness-related medical care. In some cases, Medicare may ask for a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only pay for care once the money in the WCMSA has been spent.
Reporting the settlement to Medicare
- Total payment obligation to the claimant (TPOC): Workers' compensation must submit the TPOC to CMS for individuals already enrolled in Medicare due to age or Social Security Disability Insurance, if the settlement is $25,000 or more. It's also necessary for those who will qualify for Medicare within 30 months of the settlement date, given the settlement amount is $250,000 or more.
- Additional reporting: Apart from workers' comp, individuals must also report to Medicare if they file a liability or no-fault insurance claim.
Understanding the ins and outs of workers' compensation and Medicare can help you avoid potential claim denials and reimbursement obligations, ensuring a smoother experience for all involved.
Frequently Asked Questions:
Q: How can I contact Medicare with questions?A: You can reach out to Medicare via phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048), or during certain hours, through a live chat on Medicare.gov. If you have questions about the Medicare recovery process, contact the BCRC at 855-798-2627 (TTY 855-797-2627).
Q: Is a Medicare set-aside arrangement mandatory?A: No, it's voluntary. However, if a Medicare beneficiary wants to set one up, their workers' compensation settlement must be over $25,000, or over $250,000 if they are eligible for Medicare within 30 months.
Q: What happens if WCMSA funds are misused?A: Using the funds in a Medicare set-aside arrangement for anything other than the designated purpose can lead to claim denials and the need to reimburse Medicare.
Insights:
- As of April 4, 2025, reporting is required for all full and final settlements involving Medicare beneficiaries.
- Reporting via the Section 111 process is necessary, even if CMS approval is not requested.
- Coordination with Medicare Secondary Payer (MSP) compliance and legal counsel is essential to ensure all reporting requirements are met.
- Failure to properly report a workers' compensation settlement can result in civil penalties or the denial of future Medicare benefits for the injured worker.
- To maintain transparency and avoid claim denials, health-and-wellness professionals should understand the process of healthsystems involving workers' compensation and Medicare.
- In the case of Medicare's secondary payer policy, therapies-and-treatments for work-related injuries should be covered by workers' compensation first, before Medicare takes over.
- Nutrition and other healthcare services provided to Medicare beneficiaries in connection with workers' compensation cases might need to be administered through a Medicare set-aside arrangement (WCMSA).
- When handling workers' compensation cases, it's important to be aware of the uncategorized reporting requirements for settlements, as per Medicare regulations, even if the recipient is not yet eligible for Medicare but may become eligible within a certain timeframe.
