Keeping Medicare in the Loop About Workers' Compensation Settlements
Understanding the interplay between Workers' Compensation and Medicare: crucial insights needed
Navigating the world of workers' compensation and Medicare isn't always child's play, but it's crucial to keep things straight. Not letting Medicare know about a workers' comp arrangement can land you in a pickle, as you might face claim denials and the need to reimburse Medicare.
Workers' compensation provides for employees who've suffered job-related injuries or illnesses, administered by the Office of Workers' Compensation Programs (OWCP). This program applies to federal employees, their relatives, and select other entities.
If you're currently on Medicare or soon to be, understand how workers' comp may impact Medicare's medical claim coverage. This ensures you steer clear of any medical expense complications arising from work injuries or illnesses.
How a Workers' Comp Settlement Impacts Medicare
Under Medicare's secondary payer policy, workers' compensation must take the lead on treatment costs for work-related injuries. However, if urgent expenses pop up before the compensation settlement, Medicare may pay first and initiate the Benefits Coordination & Recovery Center (BCRC) recovery process.
To steer clear of this recovery process and avoid complications, the Centers for Medicare & Medicaid Services (CMS) keeps an eye on the amount a person receives from workers' comp for injury-related medical care. In some cases, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only jump in once the WCMSA funds are exhausted.
Settlements Requiring Report to Medicare
Workers' comp must submit a total payment obligation to the claimant (TPOC) to CMS to safeguard Medicare's portion of your medical expenses. This represents the total owed to you or on your behalf.
You need to submit a TPOC if you're already on Medicare based on age or SSDI and the settlement is $25,000 or more. TPOCs are also needed if you're not yet on Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more.
Remember, you also need to report to Medicare if you file a liability or no-fault insurance claim.
Frequently Asked Questions
Get in touch with Medicare by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048) or during certain hours via live chat on Medicare.gov. If you have queries about the Medicare recovery process, dial 855-798-2627 (TTY 855-797-2627).
A Medicare set-aside is optional, but if you wish to set one up, your workers' comp settlement must exceed $25,000 or $250,000 if you'll qualify for Medicare within 30 months.
Yes, it's forbidden to use funds from a Medicare set-aside arrangement for anything other than its designated purpose. Misusing the funds can lead to claim denials and having to reimburse Medicare.
The Bottom Line
Workers' compensation serves to cover job-related injuries or illnesses for federal employees and select groups.
If you're on Medicare or heading that direction, educate yourself on how workers' comp may influence your Medicare coverage to dodge medical expense issues.
Most importantly, make sure you keep Medicare in the loop about your workers' comp agreements to avoid future claim rejections and reimbursement obligations.
Medicare Resources
For more resources to guide you through the complex land of medical insurance, drop by our Medicare hub.
- Workers' compensation, administered by the Office of Workers' Compensation Programs (OWCP), provides for employees who've suffered job-related injuries or illnesses.
- Medicare's secondary payer policy dictates that workers' compensation must take the lead on treatment costs for work-related injuries, but may pay first in cases of urgent expenses.
- If you're already on Medicare based on age or SSDI and the workers' comp settlement is $25,000 or more, you need to submit a total payment obligation to the claimant (TPOC) to CMS.
- If you're not yet on Medicare but will qualify within 30 months of the settlement date, and the settlement amount is $250,000 or more, TPOCs are also needed.
- In some cases, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for injury-related medical care funds, and misusing these funds can lead to claim denials and reimbursement obligations.
- You should also report to Medicare if you file a liability or no-fault insurance claim, and a Medicare set-aside is optional, but may be necessary if your settlement exceeds the specified thresholds.
