If you or a covered family member is entitled to benefits from a source other than your FEHB plan, such asÂ Medicare, those benefits will need to beÂ â€œcoordinated.â€
â€œCoordination of benefitsâ€ means that when you are covered by more than one type of insurance that covers the sameÂ health care expenses, one pays its benefits in full as the primary payer and the others pay a reduced benefit as aÂ secondary or third payer. When the primary payer doesnâ€™t cover a particular service but the secondary payer does, theÂ secondary payer will pay up to its benefit limitÂ as if it were the primary payer.
Coordination with Medicare
Medicare is generally for persons age 65 or over. It has four parts:
â€¢ Part A (Hospital Insurance) helps pay for inpatient hospital care, skilled nursing facility care, home healthÂ care, and hospice care. You are entitled to Part A without having to pay premiums if you or your spouseÂ worked for at least 10 years in Medicare-covered employment. (You automatically qualify if you were aÂ Federal employee on January 1, 1983.) A percentage of your salary, up to a maximum determined by the SocialÂ Security Administration, is deducted from your pay for this coverage.
â€¢ Part B (Medical Insurance) helps pay for doctorsâ€™ services, outpatient hospital care, X-rays and laboratoryÂ tests, medical equipment and supplies, home health care (if you donâ€™t have Part A), certain preventive care,Â ambulance transportation, other outpatient services, and some other medical services Part A doesnâ€™t cover,Â such as physical and occupational therapy. You must pay premiums for Part B, which are withheld from yourÂ monthly social security payment or your Civil Service Retirement System (CSRS) annuity.
â€¢ Part C (Medicare Advantage) allows you to enroll in a Medicare Advantage plan to get your MedicareÂ benefits. Medicare Advantage is the term used to describe the various private health plan choices available toÂ Medicare beneficiaries.
â€¢ Part D (Medicare Prescription Drug Coverage) is a monthly premium for Part D coverage. Most FederalÂ employees do not need to enroll in the Medicare drug program, since all Federal Employees Health BenefitsÂ Program plans will have prescription drug benefits that are at least equal to the standard Medicare prescriptionÂ drug coverage.
You should contact the Social Security Administration for detailed information on Medicare eligibility and benefits.
You may also find information on the Medicare Web Site at www.medicare.gov.
FEHB Plans and Medicare
Generally, plans under the FEHB Program provide protection against the same kind of expenses as Medicare, plus allÂ FEHB plans provide prescription drug coverage, routine physicals, and a wider range of preventive services thanÂ Medicare.Â Whether your FEHB plan or Medicare is the primary payer depends on your current employment or health status.
When Your FEHB Plan is Primary
When your FEHB Plan is primary, you should submit claims for benefits to your FEHB plan first.Â If a balance remains after the FEHB plan makes payment on the claim, you can then submit the claim and a copy of theÂ FEHB planâ€™s explanation of benefits (EOB) to Medicare.
When Medicare is Primary
When Medicare is primary, you should submit claims for benefits to Medicare first. If a balanceÂ remains after Medicare pays the claim, you can then submit the claim and a copy of Medicareâ€™s Medicare SummaryÂ Notice (MSN) or explanation of benefits (EOB) to your FEHB plan. As the secondary payer, the FEHB plan wonâ€™tÂ process your claim without the Medicare MSN or EOB.
FEHB plan carriers have made arrangements with Medicare that automatically transfer claims information to it onceÂ Medicare processes your claim, so you generally donâ€™t need to file with both.