Medicare and Workers' Compensation: Key Insights to Understand
Working With Medicare on Workers' Compensation
Navigating the intersection of workers' compensation and Medicare can be tricky, but it's crucial to avoid claim denials and unnecessary reimbursements. Here's a lowdown on how to play it smart with your workers' comp settlement and Medicare.
Workers' Comp: An OverviewWorkers' compensation covers job-related injuries or illnesses for federal employees and select groups. If you're already on Medicare or soon will be and have work-related medical expenses on the horizon, understanding how workers' comp might collide with Medicare can save you from medical billing complications.
How Does a Work Comp Settlement Impact Medicare?
The Medicare Secondary Payer (MSP) rule mandates that workers' comp should be the primary payer for work-related injuries. If immediate medical costs arise before the worker receives their work comp settlement, Medicare might cover initially and recover the costs through the Benefits Coordination & Recovery Center (BCRC). To avoid a recovery process and potential claim denials, the Centers for Medicare & Medicaid Services (CMS) often monitors the recipient's work comp settlement for injury- or illness-related medical care. In some cases, Medicare may ask for a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) to hold these funds and cover care only after they've been exhausted.
Reportable Settlements and Claims
Workers' comp must submit the Total Payment Obligation to the Claimant (TPOC) to CMS to ensure Medicare covers the appropriate portion of an individual's medical expenses. Notably, a TPOC is necessary if a person is already enrolled in Medicare based on age or Social Security Disability Insurance, and the settlement is $25,000 or more, or if the person isn't yet enrolled in Medicare but will within 30 months, and the settlement amount is $250,000 or more. In addition, liability or no-fault insurance claims must also be reported to Medicare.
Workers' Comp and Medicare FAQ
Questions about Medicare, the recovery process, or WCMSAs can be answered by contacting Medicare at 800-MEDICARE, or during certain hours, through a live chat on Medicare.gov. For questions related to the Medicare recovery process, call the BCRC at 855-798-2627.
What's a WCMSA, and Is It Mandatory?
Though voluntary, a Medicare beneficiary needs a WCMSA if their work comp settlement is over $25,000 or over $250,000 if they'll be eligible for Medicare within 30 months.
Utilizing WCMSA Funds
Misusing WCMSA funds for purposes other than intended can result in claim denials and the need to reimburse Medicare.
Key Takeaways
- Workers' compensation is insurance for job-related injuries or illnesses for federal employees and other select groups
- Educate yourself about the impact of workers' compensation on your Medicare coverage to avoid medical expense complications
- Keep Medicare informed about your workers' compensation arrangements to prevent future claim denials and reimbursements
Resources
For more guidance navigating the complex medical insurance landscape, visit our Medicare hub.
- To ensure smooth handling of work-related medical expenses, it's essential to understand how health systems like Medicare can interact with workers' compensation, particularly for workplace wellness and health-and-wellness.
- In the context of workers' compensation, the Medicare Secondary Payer (MSP) rule specifies that therapies-and-treatments related to job-related injuries should be covered primarily by workers' comp.
- When a work comp settlement is ongoing or to be expected, the Centers for Medicare & Medicaid Services (CMS) may ask for a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) to allocate funds for injury- or illness-related medical care, preventing unnecessary reimbursements.
- Managing a health-and-wellness plan that includes nutrition and other aspects should carefully consider the implications of Medicare and WCMSAs, as misusing the dedicated funds may result in claim denials and reimbursement obligations.
