Injuring yourself on the job can be physically and financially stressful, particularly for older workers who rely on Medicare for their healthcare coverage.
If you're 65 or older and still working, or are disabled and eligible for Medicare, you need to know how Medicare and Workers' Compensation interact. Most seniors don't know how these two systems fit together, and this leaves them with unexpected medical bills or delayed benefits. This guide will help you navigate your benefits, rights, and traps in handling an on-the-job injury.
How Workers' Compensation and Medicare Interact
Workers' Compensation (WC) is a state-mandated insurance program designed to pay for benefits to the employees who become injured on the job. Medical costs, loss of time, and rehabilitation resulting from the injury are covered under it. Medicare, however, is a governmental health insurance plan for people primarily 65 or older, and for disabled workers under 65.
If a Medicare beneficiary is injured on the job, the first payer is Workers' Compensation. That is, WC covers all the treatment and medical care for the on-the-job injury before Medicare becomes effective. But things don't always go so smoothly, and there are disputes over coverage.
Who Pays First? Primary and Secondary Coverage
Medicare also has tight coordination rules of who pays first if there are more than one insurance company involved. Here's how it operates:
If Workers' Compensation Approves the Claim: WC pays for all of the medical bills of the injury, including doctor's visits, hospitalization, drugs, and therapy. Medicare will not cover any costs that directly relate to the work-related injury.If Workers' Compensation Denies or Delays the Claim: Medicare can cover required treatments in the meantime. However, if WC pays the claim subsequently, Medicare might need to be reimbursed for the payments.If You Receive a Workers' Compensation Settlement: If your case settles for a lump sum, part of the money will be set aside for future medical treatment. Medicare must be considered in these settlements so that it won't deny future treatment of the injury.Medicare Set-Asides (MSA): What You Should Know
If an eligible injured worker settles with Workers' Compensation, a Medicare Set-Aside (MSA) agreement may be required. This is some of the settlement money set aside to pay for future medical care for the injury.The money in the MSA must be exhausted prior to Medicare reimbursing subsequent medical bills due to the injury.Inefficient distribution of an MSA may lead to Medicare's refusal to pay for the treatments for the work-related injury.The Centers for Medicare & Medicaid Services (CMS) also reviews and certifies MSAs to ensure that they meet federal standards.Typical Problems When Handling Medicare and Workers' Compensation
Most of the elderly are faced with challenges and disorientation in assimilating these two systems. Some of the most prevalent challenges include:
Long Delays in Rulings on Workers' Compensation – Some take years or even decades, keeping seniors financially suspended in limbo waiting for a ruling.Surprise Medicare Reimbursement Requests – If Medicare does reimburse for work injury treatment in advance of WC approval of a claim, it will subsequently request back payment from the beneficiary.Misclassification – The main insurers try to pass the cost on to Medicare by claiming that treatments of injuries have no relation to the workplace injury. Seniors should be careful to protect their rights.What to Do if You Are a Medicare Beneficiary Injured on the Job
Report the Injury Right Away – Notify your employer right away when the injury occurs to initiate the process for the Workers' Compensation claim.Seek Medical Treatment – Make sure that all treatments are documented to prevent future coverage issues.Notify Medicare of the Claim – Medicare must be notified of all WC claims so that benefits can be coordinated.Monitor Your Bills – Monitor all of the medical bills so that Workers' Compensation is covering the appropriate expenses.Seek Legal Advice – If there are disputes regarding coverage or settlements, seeking legal advice will safeguard your rights and ensure your highest benefits. Last Word For workers who are covered by Medicare, a work-related injury can raise complex coverage issues.Understanding Workers' Compensation and Medicare regulations is crucial in preventing surprise expenses and gaps in coverage. Being informed, being an advocate for your rights, and making sure you are in compliance with Medicare Set-Aside regulations will help you get the maximum out of your benefits and reduce financial pressure. If you or a loved one is having trouble with Medicare and Workers' Compensation, don't jeopardize your coverage. Take action now to make sure you get the full compensation you deserve while safeguarding your Medicare eligibility for the future.
