Guidance on Workers' Compensation and Medicare Interplay: Key Insights
Workers' Compensation and Medicare: What You Need to Know
Navigating the intersection of workers' compensation and Medicare is essential to avoid complications and ensnarements with medical expenses for work-related injuries. Here's a quick guide on how to handle workers' compensation settlements when you're on Medicare.
The Impact of Workers' Comp on Medicare
Under Medicare's Secondary Payer policy, workers' compensation must foot the bill for treatment of work-related injuries before Medicare steps in. However, if immediate medical expenses arise before the settlement comes in, Medicare might mollify the expenses and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To dodge such a recovery process, and to establish transparency, Centers for Medicare & Medicaid Services (CMS) encourages monitoring workers' comp payments for medical treatments arising from job-related injuries or illnesses. In some cases, Medicare may advocate for a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare won't cover any additional medical costs until the WCMSA funds have been exhausted.
What Requires Reporting to Medicare
Workers' comp must relay a Total Payment Obligation to the Claimant (TPOC) to CMS to ensure Medicare covers a person's medical expenses appropriately. This represents the total sum of workers' comp owed to the person or on their behalf.
Submitting a TPOC is essential under three scenarios:
- The person is enrolled in Medicare based on age or Social Security Disability Insurance (SSDI), and the settlement is $25,000 or more.
- The person is yet to enroll in Medicare but will be eligible within 30 months of the settlement date, and the settlement amount is $250,000 or more.
- Besides workers' comp, the person must report to Medicare if they file a liability or no-fault insurance claim.
FAQs
Any questions can be directed to Medicare via phone (800-MEDICARE / TTY 877-486-2048) or live chat on Medicare.gov during specific hours. Inquiries about the Medicare recovery process can also be lodged with the BCRC at 855-798-2627 (TTY 855-797-2627).
Fun fact: A Medicare set-aside is voluntary but becomes mandatory if the workers' compensation settlement is over the thresholds mentioned earlier. Misusing WCMSA funds can lead to claim denials and reimbursement obligations.
For further resources to help navigate the complexities of medical insurance, visit our Medicare hub.
Insights: While reporting all settlements involving Medicare beneficiaries is necessary, for settlements below certain thresholds, an MSA doesn't need to be approved by CMS for reporting purposes. However, all settlement details, including the date of injury, settlement amount, and any allocation for future medical care, must be reported through the Section 111 Mandatory Insurer Reporting process. This information helps ensure that Medicare's interests are protected and beneficiaries use the set-aside funds before seeking Medicare coverage for related treatments. Benficiaries must also use the set-aside funds before Medicare covers any additional medical costs.
- Under Medicare's Secondary Payer policy, workers' compensation must pay for treatment of work-related injuries before Medicare steps in, but Medicare might cover initial expenses if the settlement is delayed.
- The Centers for Medicare & Medicaid Services encourages monitoring workers' comp payments for medical treatments arising from job-related injuries or illnesses, and in some cases, Medicare may advocate for a workers' compensation Medicare set-aside arrangement (WCMSA).
- Workers' comp must relay a Total Payment Obligation to the Claimant (TPOC) to CMS in specific scenarios for Medicare to cover a person's medical expenses appropriately.
- Any settlement involving Medicare beneficiaries, even those under certain thresholds, should be reported through the Section 111 Mandatory Insurer Reporting process to ensure Medicare's interests are protected.
- Misusing WCMSA funds can lead to claim denials and reimbursement obligations, making it essential to use the set-aside funds before seeking Medicare coverage for related treatments.
- A voluntary Medicare set-aside can become mandatory if the workers' compensation settlement is over the mentioned thresholds.
- For further resources on navigating medical insurance complexities, visit the Medicare hub, which covers health systems, workplace-wellness, health-and-wellness, fitness-and-exercise, therapies-and-treatments, and nutrition, in addition to workers' compensation and Medicare.
