Navigating Workers' Compensation and Medicare: Essential Information to Understand
Navigating the waters between workers' compensation and Medicare can be a daunting task, but it's crucial to stay afloat. Failing to report a workers' compensation arrangement could lead to claim denials and reimbursing Medicare.
Worker's compensation is insurance for those injured or ill due to job-related incidents. It falls under the Office of Workers' Compensation Programs (OWCP) within the Department of Labor, benefiting federal employees, their families, and other eligible entities.
If you're already enrolled in Medicare or soon will be, understanding how your workers' compensation benefits might impact Medicare's coverage is vital to avoid complications with medical costs for workplace injuries or illnesses.
Workers' Compensation and Medicare: A Juggling Act
Medicare, as a secondary payer, relies on workers' compensation to cover treatment related to work-related injuries first. If immediate medical expenses arise before you receive your workers' compensation settlement, Medicare may pay first, initiating a recovery process managed by the Benefits Coordination & Recovery Center (BCRC). To avoid this, the Centers for Medicare & Medicaid Services (CMS) often monitors the amount a person receives from workers' compensation for injury-related medical care. In some cases, Medicare may request a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds.
When to Report Workers' Compensation Settlements to Medicare
Workers' compensation settlements that exceed certain thresholds require reporting to Medicare:
- If you're already enrolled in Medicare and the settlement is $25,000 or more, submit a Total Payment Obligation to the Claimant (TPOC) to CMS.
- If you're not yet enrolled in Medicare but will be within 30 months of the settlement date and the settlement is $250,000 or more, also submit a TPOC.
Additionally, if you file a liability or no-fault insurance claim, you must report this to Medicare as well.
Frequently Asked Questions
Reach out to Medicare with any questions at 800-MEDICARE (800-633-4227) or via a live chat on Medicare.gov. For questions about the Medicare recovery process, contact the BCRC at 855-798-2627.
A Medicare set-aside is voluntary, but if you want to set one up, your workers' compensation settlement must be over $25,000, or over $250,000 if you'll be eligible for Medicare within 30 months. It's prohibited to use the money in a Medicare set-aside arrangement for anything other than the designated purpose, as misuse can lead to claim denials and reimbursement obligations.
Learn More: Medicare Set-Aside Best Practices
To report a workers' compensation settlement and avoid potential claim denials or reimbursement obligations:
- Prepare an MSA Allocation Report if necessary, detailing anticipated Medicare allowable, injury-related expenses.
- Report the settlement to the Centers for Medicare and Medicaid Services (CMS). Register with CMS and submit required information, including the MSA Allocation details, to ensure compliance with Medicare reporting requirements.
- Submit an annual attestation to the Benefits Coordination & Recovery Center (BCRC) to confirm that MSA funds were used appropriately for Medicare-covered, case-related expenses.
- Maintain detailed records of all medical expenses covered by the MSA.
- Ensure that MSA funds are used strictly for Medicare-covered, case-related treatment as per CMS guidelines for accurate accounting and compliance.
By following these steps, you can ensure proper reporting and maintain a hassle-free relationship between your workers' compensation and Medicare benefits.
For More Resources Visit Our Medicare Hub
To help you navigate the complex world of medical insurance, check out our Medicare hub for valuable resources.
- The Centers for Medicare & Medicaid Services (CMS) often monitor the amount a person receives from workers' compensation for injury-related medical care.
- To avoid potential claim denials or reimbursement obligations when reporting a workers' compensation settlement, one should submit an MSA Allocation Report, register with CMS, and submit required information to ensure compliance with Medicare reporting requirements.
- A Medicare set-aside arrangement (WCMSA) may be requested by Medicare for the funds received from workers' compensation.
- Understanding how workers' compensation benefits might impact Medicare's coverage is crucial when enrolled in or planning to enroll in Medicare.
