The US Department of Labor’s Office of Workers’ Compensation Programs provides compensation and medical benefits for illnesses and diseases from occupational exposure to certain chemicals and radiation. These benefits are covered under the Energy Employees Occupational Illness Compensation Program (EEOICPA or Act) enacted in October 2000. Medicare is a federal government health insurance for persons aged 65 and above, and younger persons suffering from End-Stage Renal Disease, and those living with disabilities. The federal government offers Medicaid to persons with limited income in collaboration with states.
For eligible Medicare, Medicaid, and EEOICPA claimants, EEOICPA is the primary payor. If the DOL doesn’t authorize the payments within 120 days, Medicare may make conditional payments that must be paid back from the workers’ compensation program. Medicaid is always the last payor.
Medicare, Medicaid, and EEOICPA
For EEOICPA claimants with Medicare, the Energy Employees Occupational Illness Compensation Program is the primary payer for injury-related medical costs. However, if the Department of Labor doesn’t authorize the payments within 120 days of filing a claim, Medicare may make conditional payments for its covered services. In such a case, Medicare payments related to occupational injuries/illnesses are temporarily made in place of the workers’ compensation and must be paid back once the workers’ compensation program benefits are made.
However, if the workers’ compensation program denies the claim and benefits are not paid, Medicare may pay for Medicare-covered services on a non-conditional basis. In this case, the beneficiary doesn’t have to pay back.
In some cases, the workers’ compensation program payments do not fully cover the required medical expenses for a covered illness, and Medicare may pay for Medicare-covered services that are not covered. Medicaid is always the last payor for eligible beneficiaries. Claimants are advised to notify Medicare once they file for workers’ compensation claims.
If you have secondary insurance, such as deductibles, copayments, and coinsurances, these secondary insurances may also pay after the primary insurer. If Medicare, Medicaid, or private insurance is paying your medical bills, do not disturb the situation to avoid complicating the process, as DOL, Medicare, Medicaid, or private insurance may deny payments for your bills.
Medicare and Medicaid
What is Medicare? Medicare is a health insurance provided by the federal government for persons aged 65 and above and younger persons suffering from End-Stage Renal Disease, and those living with disabilities.
What is Medicaid? Medicaid is a special medical care program the federal government offers in collaboration with states to persons with limited income. The program is funded by taxpayers, and it covers services that are not offered by Medicare, such as care in nursing homes and personal care. Eligibility for Medicaid is based on the individual’s income and resources and differs across different states. In some states, persons with certain incomes exceeding the required minimum must spend down through cost sharing or covering some expenses until their income reaches that required for Medicaid eligibility.
EEOICPA overview
The EEOICPA program is subdivided into two parts, A & E.
Part B, effective from July 31, 2001, compensates the Department of Energy (DOE) current and former employees or their survivors and its recognized vendors, contractors, and subcontractors who were diagnosed with radiogenic cancer, chronic beryllium disease, beryllium sensitivity, or chronic silicosis, as a result of exposure to radiation, beryllium, or silica during their employment at covered facilities. It also compensates individuals or their eligible survivors for benefits awarded by the Department of Justice under Section 5 of the Radiation Exposure Compensation Act (RECA). Eligible claimants get $150,000 and payment for medical expenses for covered illnesses.
Part E, which took effect on October 28, 2004, compensates DOE contractor and subcontractor employees, eligible survivors of such employees, and uranium miners, millers, and ore transporters for any occupational illnesses causally linked to toxic exposures in the DOE or mining work environment as defined by RECA Section 5. The benefits under Part E also include wage loss, impairment, and survivor benefits, and they should not exceed $250,000.
EEOICPA provides medical benefits claimed for accepted medical conditions from the day of filing a claim. Additionally, EEOICPA covers consequential illnesses incurred due to an accepted condition. These are new and separate medical problems that a doctor identifies as occurring due to the original covered illness.
Services and benefits covered by EEOICPA include all medical expenses related to the covered illness, such as doctor and treatment costs, inpatient and outpatient hospital charges, diagnostic laboratory, and radiological testing, home and Residential Health Care, drugs prescribed by a physician, travel for treatment expenditure, necessary medical equipment and ambulance services.
DEEOIC is always the primary payer for care linked to accepted illnesses. Thus, it is responsible for the total cost of treatment of an employee’s accepted illness. Claimants are required to submit costs of any treatment for uncovered illnesses to their private insurance, Medicare or Medicaid. Claimants eligible for EEOICPA benefits do not pay deductibles or copayments. It is also worth noting that EEOICPA medical benefits are paid on a fee schedule whereby the service provider agrees to receive payments at a set rate.
EEOICPA benefits as an asset and taxation
As stated in the US Constitution (42 U.S.C. § 7385e), compensation or benefits provided to an individual, such as the EEOICPA, are not taxable. The law states that such benefits shall be treated for purposes of the Internal Revenue laws of the United States as damages for human suffering. Also, they shall not be included as income or resources for purposes of determining eligibility to receive benefits described in section 3803(c)(2)(C) of title 31 or the amounts of such benefits– referring to benefits intended for the personal use of the individual who receives them or for a member of the individual’s family such as supplemental security income program, old age, survivors, and disability insurance benefits, etc.)
EEOICPA compensation benefits cannot be used as a resource for means-tested federal (or state programs). Also, these benefits cannot be used as a resource for Medicaid, welfare, food stamps, federal housing assistance (section 8 housing assistance), and Native American benefits. As a result, EEOICPA compensation is supposed to compensate, not replace other benefits. For example, it would be a mess if those in nursing homes that Medicaid is paying would no longer be eligible or if this compensation would go to the nursing home.
Reimbursements
Those who pay medical bills for EEOICPA-covered illnesses should keep their receipts for reimbursement. Reimbursements have an expiry period of no more than one year after the end of the calendar year during which the expenses were incurred or the claim was accepted. For instance, expenses incurred on any day in 2023 should be submitted no later than December 31, 2024.
EEOICPA benefits Transfer and Garnishing
As stipulated in section 7385f(a) of the Act, EEOICPA benefits cannot be assigned or transferred. However, provisions of the Social Security Act (42 U.S.C. 659) and regulations issued by the Office of Personnel Management at 5 CFR part 581 permit the garnishment of payments of EEOICPA monetary benefits to collect overdue alimony and child support. Garnish requests should be submitted to the district office handling the EEOICPA claim, accompanied by a copy of the pertinent state agency or court order.
EEOICPA benefits fraud
The Department of Justice may impose penalties on those who file false and fraudulent claims or statements with the federal government concerning a claim under the EEOICPA Act (as defined in 18 U.S.C. 1001). Enforcement of criminal provisions that may apply to claims under the Act is within the jurisdiction of the Department of Justice. Also, civil penalties and assessments may be imposed against persons or entities who make, submit, present, or cause to be made, submitted, or presented false, fictitious, or fraudulent claims or written statements to OWCP concerning a claim under EEOICPA.
A beneficiary who is found or pleads guilty to defrauding the government in connection with a claim for EEOICPA benefits or any other workers’ compensation program forfeits any entitlement to any further benefits for any injury, illness, or death covered by this part for which the time of injury was on or before the date of such guilty plea or verdict, effective the date either the guilty plea is accepted, or a verdict of guilty is returned after trial. Any subsequent change in or recurrence of the beneficiary’s medical condition does not affect this termination of entitlement.