Understanding the Intersection of Workers' Compensation Benefits and Medicare Coverage: Key Points to Consider
Understanding the Interplay Between Workers' Compensation and Medicare is Essential
Crucial notification of workers' compensation arrangements to Medicare is imperative to prevent claim denials and potential reimbursement obligations.
Workers' compensation, an insurance benefits program for employees who sustain job-related injuries or illnesses, is governed by the Office of Workers' Compensation Programs (OWCP) under the Department of Labor. This coverage extends to federal workers, their families, and specific other entities.
Individuals enrolled in Medicare or approaching eligibility should be cognizant of how their workers' compensation benefits may impact Medicare's coverage of medical claims related to work-related injuries. Neglecting this understanding could potentially lead to issues with medical costs.
Workers' Compensation Settlements and Medicare
In compliance with Medicare's secondary payer policy, workers' compensation must cover treatment costs for work-related injuries before Medicare provides coverage. If immediate expenses arise before the recipient receives their workers' compensation settlement, Medicare might initially pay for the treatment, with a subsequent recovery process handled by the Benefits Coordination & Recovery Center (BCRC).
To avoid recovery processes, the Centers for Medicare & Medicaid Services (CMS) generally keeps tabs on the amount a person receives from workers' compensation for injury- or illness-related medical care. In certain cases, a workers' compensation Medicare set-aside arrangement (WCMSA) might be required by Medicare, with the program covering only the care once the WCMSA funds have been exhausted.
Reporting Workers' Compensation Settlements to Medicare
A workers' compensation total payment obligation to the claimant (TPOC) must be submitted to CMS to ensure Medicare pays the appropriate portion of a claimant's medical expenses. This is necessary for those currently enrolled in Medicare or those who will qualify within 30 months of the settlement date, provided the settlement amount is $25,000 or more.
In addition to workers' comp, a person must report to Medicare if they file a liability or no-fault insurance claim.
For detailed information about Medicare set-asides, please visit our Medicare hub. It's essential to understand these regulations to protect your Medicare coverage and avoid potential complications with medical costs resulting from work-related injuries. Additionally, do not overlook the importance of reporting workers' compensation agreements to prevent future claim rejections and reimbursement obligations.
For more information, please contact Medicare at 800-MEDICARE (800-633-4227, TTY 877-486-2048), or through live chat on Medicare.gov during select hours. If you have questions about the Medicare recovery process, reach out to the BCRC at 855-798-2627 (TTY 855-797-2627).
Please be aware that the use of funds in a Medicare set-aside arrangement (such as a WCMSA) should be restricted to the purpose for which they were designated, and misusing the funds can lead to claim denials and the need for reimbursement to Medicare.
[1] Centers for Medicare and Medicaid Services (CMS). (2023). Medicare Set-Aside Arrangements (MSAs). Retrieved from https://www.cms.gov/Medicare/Medicare-Program-Integrity-Protections/Medicare-Set-Aside-Program-Artifacts/NCIC-aciones-Final-Rule-Fact-Sheet.pdf[2] Centers for Medicare and Medicaid Services (CMS). (2023). Final Rule on MSA & Workers' Compensation. Retrieved from https://www.federalregister.gov/documents/2023/04/04/2023-07296/medicare-set-aside-arrangements-and-workers-compensation-final-rule[3] Centers for Medicare and Medicaid Services (CMS). (2023). Section 111 Reporting – Main Menu. Retrieved from https://data.cms.gov/Medicare-Set-Aside-Allocation-Reports/MSAR_Section-111-Main-Menu/xgrb-s97v[4] Centers for Medicare and Medicaid Services (CMS). (2023). Workers’ Compensation Medicare Set-Aside Arrangement Fact Sheet. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/Section-111-Reports/WCM/WCM-Fact-Sheets-and-News-items.html#[5] Centers for Medicare and Medicaid Services (CMS). (2023). Medicare Secondary Payer (MSP) Statute. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/MedicarePart-D/Downloads/Medicare-Secondary-Payer-(MSP)-Statute.pdf
- The healthcare sector, including health-and-wellness, therapies-and-treatments, and nutrition, should be mindful of the interplay between workers' compensation and Medicare for integrated healthcare services, as the Centers for Medicare & Medicaid Services (CMS) has set guidelines to ensure proper distributions of coverage.
- The science behind Medicare's secondary payer policy mandates that workers' compensation cover treatment costs related to work-injuries before Medicare comes into play, and reporting workers' compensation agreements is crucial to prevent reimbursement obligations.
- Businesses offering healthsystems and work-related insurance, such as Medicare, must report to CMS any workers' compensation total payment obligation to the claimant (TPOC) to determine the appropriate portion of medical expenses covered.
- The importance of understanding the regulations governing workers' compensation settlements, as well as reporting requirements, extends beyond health-and-uncategorized sectors to protect Medicare coverage and avoid complications with medical costs in the health-and-wellness industry.
