Navigating Workers' Compensation and Medicare Interests: Key Insights to Consider
Navigating the labyrinth of workers' comp and Medicare can save you from future headaches. Here's a no-nonsense guide on how to navigate this complex terrain.
Workers' compensation is the insurance that keeps federal employees and certain other entities afloat when they get injured or ill due to their jobs. The Office of Workers' Compensation Programs (OWCP) under the Department of Labor takes care of this benefit.
If you're either currently on Medicare or about to qualify, it's essential to understand how workers' comp can impact Medicare's coverage of your medical bills for work-related injuries. This knowledge can prevent needless complications with medical costs.
How does a workers' comp settlement affect Medicare?
In the grand scheme of things, Medicare generally considers workers' comp as the primary payer for any treatment related to a work-related injury. However, if you face immediate medical expenses before getting your workers' comp settlement, Medicare might extend a helping hand first and initiate a recovery process managed by the Benefits Coordination & Recovery Center (BCRC).
To avoid the recovery process and its complexities, the Centers for Medicare & Medicaid Services (CMS) often monitors the amount you receive from workers' comp for injury- or illness-related medical care. In some cases, CMS may even ask for the establishment of a workers' compensation Medicare set-aside arrangement (WCMSA) for these funds. Only after exhausting the money in the WCMSA will Medicare cover your care.
What settlements need to be reported to Medicare?
When it comes to settling workers' comp claims, you leave no stone unturned and report the total payment obligation to the claimant (TPOC) to CMS. This is crucial if you're already on Medicare based on your age or Social Security Disability Insurance, and the settlement is $25,000 or more. Additionally, if you're not yet on Medicare but are poised to qualify within 30 months of the settlement date and the settlement is $250,000 or more, reporting the TPOC to CMS is non-negotiable.
It's also essential to report to Medicare if you're planning to file a liability or no-fault insurance claim.
Frequently asked questions
If you've got questions about your specific situation, you can hit up Medicare by phone at 800-MEDICARE or (800-633-4227, TTY 877-486-2048). During certain hours, a live chat is also available on Medicare.gov. For queries about the Medicare recovery process, you can give the Benefits Coordination & Recovery Center (BCRC) a buzz at 855-798-2627 (TTY 855-797-2627).
As of April 4, 2025, a Medicare set-aside is voluntary, but if you want one, your workers' comp settlement should surpass $25,000. If you're eligible for Medicare within 30 months, the limit hikes to $250,000.
Absolutely. Using the money in a Medicare set-aside arrangement (WCMSA) for anything other than its intended purpose is a big no-no and can result in claim denials and reimbursement obligations.
The bottom line
Workers' compensation insurance is a lifesaver for those injured on the job. As a federal employee or part of the designated group, it's crucial to stay informed about how workers' comp can affect your Medicare coverage to avoid health care hiccups down the line.
Don't forget to inform Medicare about your workers' comp agreements to dodge potential claim rejections and unnecessary reimbursement obligations. For more resources to help you navigate the intricate world of medical insurance, check out our comprehensive Medicare hub.
- In a workers' comp settlement, the Medicare program generally considers it as the primary payer for medical treatment related to work-related injuries, but it might extend help before the settlement if there are immediate medical expenses.
- When settling a workers' comp claim, it is mandated to report the total payment obligation to the claimant (TPOC) to the Centers for Medicare & Medicaid Services (CMS) if the settlement is $25,000 or more and the claimant is already on Medicare or qualifies based on age or Social Security Disability Insurance.
- If the claimant is not yet on Medicare but is eligible within 30 months of the settlement date and the settlement is $250,000 or more, reporting the TPOC to CMS is unavoidable. Reporting is also necessary when filing a liability or no-fault insurance claim.
- A Medicare set-aside arrangement (WCMSA) may be required by CMS to monitor funds allocated for injury- or illness-related medical care. Only after exhausting the money in the WCMSA will Medicare cover the care. As of April 4, 2025, a Medicare set-aside becomes voluntary, but it's recommended for settlements surpassing $25,000 for those eligible for Medicare within 30 months. Using the funds for purposes other than intended can lead to claim denials and reimbursement obligations.
