Understanding the Interplay between Workers' Compensation and Medicare: Essential Insights
Uncovering the Nitty-Gritty of Workers' Compensation and Medicare Interaction
Navigating the intersection of workers' compensation and Medicare can be a tricky business for those who've sustained job-related injuries or illnesses. Here's a lowdown on how it works:
The workers' comp-Medicare dance
- First dibs on payments: Under Medicare's secondary payer policy, workers' compensation must foot the bill for any treatment related to a work-related injury before Medicare chips in.
- Medicare stepping in: In situations where immediate medical expenses crop up before the workers' compensation settlement arrives, Medicare might pay first and initiate recovery proceedings managed by the Benefits Coordination & Recovery Center (BCRC). To avoid such situations, the Centers for Medicare & Medicaid Services (CMS) keeps a close eye on the amount a person receives from workers' compensation for their injury or illness-related medical care.
- Getting ready for the dance: In some cases, Medicare might ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Medicare will only cover the care after all the money in the WCMSA has been used up.
Reporting the good news
- Spilling the beans: Workers' compensation must submit a total payment obligation to the claimant (TPOC) to CMS so that Medicare covers the appropriate portion of a person’s medical expenses. This is necessary if a person is already enrolled in Medicare based on their age or based on receiving Social Security Disability Insurance and if the settlement is $25,000 or more.
- Spilling it when it's due: TPOCs are also needed if the person is not currently enrolled in Medicare but will qualify for the program within 30 months of the settlement date, and the settlement amount is $250,000 or more.
- Pulling out all the stops: In addition to workers' comp, a person must report to Medicare if they file a liability or no-fault insurance claim.
FAQs
- Talking to Medicare: A person can contact Medicare with any question by phone at 800-MEDICARE (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is also available on Medicare.gov. If a person has questions about the Medicare recovery process, they can contact the BCRC at 855-798-2627 (TTY 855-797-2627).
- Getting help with a Medicare set-aside: A Medicare set-aside is voluntary. However, if a Medicare beneficiary wants to set one up, their workers' compensation settlement must be over $25,000. Alternatively, it must be over $250,000 if they are eligible for Medicare within 30 months.
- Misusing the money: It is prohibited to use the money in a Medicare set-aside arrangement such as a WCMSA for any purpose other than the one for which it is designated. Misusing the money can lead to claim denials and having to reimburse Medicare.
"Learn more: What to know about Medicare set-aside## Takeaway
- What's workers' compensation? It's essentially an insurance policy for federal employees and certain other groups to cover job-related injuries or illnesses.
- Get informed: If you're enrolled in Medicare or will soon be, educate yourself on how workers' compensation may affect your Medicare coverage to prevent issues with medical expenses.
- Keep Medicare in the loop: Make sure to inform Medicare about workers' compensation agreements to avoid future claim rejections and reimbursement obligations.
- In the realm of health-and-wellness, Medicare's secondary payer policy dictates that healthsystems offering workers' compensation must pay for treatment related to work-related injuries before Medicare steps in.
- Therapies-and-treatments covered by Medicare could be delayed if the amount a person receives from workers' compensation is not adequately managed, leading to the establishment of a Medicare set-aside arrangement (WCMSA) for coordinated fund allocation.
- Nutritional care and medical expenses could be subject to recovery proceedings managed by the Benefits Coordination & Recovery Center (BCRC) if payments from workers' compensation come after the initial Medicare payments.
- Understanding the science behind the interaction between workers' compensation and Medicare is crucial, as failure to report Total Payment Obligation to the claimant (TPOC) to Medicare could impact future Medicare eligibility and medical expense coverage.
