Coordinating Federal Employee Healthcare Benefits with Medicare

If you or a covered family member is entitled to benefits from a source other than your FEHB plan, such as Medicare, those benefits will need to be “coordinated.”

“Coordination of benefits” means that when you are covered by more than one type of insurance that covers the same health care expenses, one pays its benefits in full as the primary payer and the others pay a reduced benefit as a secondary or third payer. When the primary payer doesn’t cover a particular service but the secondary payer does, the secondary payer will pay up to its benefit limit as if it were the primary payer.

Coordination with Medicare

Medicare is generally for persons age 65 or over. It has four parts:

• Part A (Hospital Insurance) helps pay for inpatient hospital care, skilled nursing facility care, home health care, and hospice care. You are entitled to Part A without having to pay premiums if you or your spouse worked for at least 10 years in Medicare-covered employment. (You automatically qualify if you were a Federal employee on January 1, 1983.) A percentage of your salary, up to a maximum determined by the Social Security Administration, is deducted from your pay for this coverage.

• Part B (Medical Insurance) helps pay for doctors’ services, outpatient hospital care, X-rays and laboratory tests, medical equipment and supplies, home health care (if you don’t have Part A), certain preventive care, ambulance transportation, other outpatient services, and some other medical services Part A doesn’t cover, such as physical and occupational therapy. You must pay premiums for Part B, which are withheld from your monthly social security payment or your Civil Service Retirement System (CSRS) annuity.

• Part C (Medicare Advantage) allows you to enroll in a Medicare Advantage plan to get your Medicare benefits. Medicare Advantage is the term used to describe the various private health plan choices available to Medicare beneficiaries.

• Part D (Medicare Prescription Drug Coverage) is a monthly premium for Part D coverage. Most Federal employees do not need to enroll in the Medicare drug program, since all Federal Employees Health Benefits Program plans will have prescription drug benefits that are at least equal to the standard Medicare prescription 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 all FEHB plans provide prescription drug coverage, routine physicals, and a wider range of preventive services than Medicare. 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. If a balance remains after the FEHB plan makes payment on the claim, you can then submit the claim and a copy of the FEHB plan’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 balance remains after Medicare pays the claim, you can then submit the claim and a copy of Medicare’s Medicare Summary Notice (MSN) or explanation of benefits (EOB) to your FEHB plan. As the secondary payer, the FEHB plan won’t process your claim without the Medicare MSN or EOB.

FEHB plan carriers have made arrangements with Medicare that automatically transfer claims information to it once Medicare processes your claim, so you generally don’t need to file with both.

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