Coordination of Medicare and FEHB Benefits

Coordination of Medicare and FEHB Benefits

Frequently Asked Questions

Does My FEHB Plan or Medicare Pay Benefits First?

Medicare law and regulations determine whether Medicare or FEHB is primary (that is, pays benefits first).

Medicare automatically transfers claims information to your FEHB plan once your claim is processed, so you generally don't need to file a claim with both. You will receive an Explanation of Benefits (EOB) from your FEHB plan and an EOB or Medicare Summary Notice (MSN) from Medicare. If you have to file with the secondary payer, send along the EOB or MSN you get from the primary payer.

When is My FEHB Plan the Primary Payer?

Your FEHB Plan must pay benefits first when you are an active Federal employee or reemployed annuitant and either you or your covered spouse has Medicare. (There is an exception if your reemployment position is excluded from FEHB coverage or you are enrolled in Medicare Part B only.)

Your FEHB Plan must also pay benefits first for you or a covered family member during the first 30 months of eligibility or entitlement to Part A benefits because of End Stage Renal Disease (ESRD), regardless of your employment status, unless Medicare (based on age or disability) was your primary payer on the day before you became eligible for Medicare Part A due to ESRD.

Your FEHB Plan must also pay benefits first when you are under age 65, entitled to Medicare on the basis of disability, and covered under FEHB based on you or your spouse's employment status.

When is Medicare the Primary Payer?

Medicare must pay benefits first when you are an annuitant, (unless you are a reemployed annuitant, see above), and either you or your covered spouse has Medicare. (This includes Federal judges who retired under title 28, U.S.C., and Tax Court judges who retired under Section 7447 of title 26, U.S.C.)

If Medicare was the primary payer prior to the onset of End Stage Renal Disease, Medicare will continue to be primary during the 30-month coordination period. However, if Medicare was secondary prior to the onset of End Stage Renal Disease, it will continue to be secondary until the 30-month coordination period has expired. After the 30-month coordination period has expired, Medicare will be primary regardless of your employment status.

If I Continue to Work Past Age 65, is My FEHB Coverage Still Primary?

Your FEHB coverage will be your primary coverage until you retire.

I am Retired With FEHB and Medicare Coverage. I am Also Covered Under My Spouse's Insurance Policy Through Work. Which Plan is Primary?

Since you are retired but covered under your working spouse's policy, your spouse's policy is your primary coverage. Medicare will pay secondary benefits and your FEHB plan will pay third.

Do My FEHB Premiums Change When Medicare Becomes Primary?

No. You will continue to pay the same premiums, unless you change to another plan or option.

Medicare & FEHB Primary Payer Chart

When Either You or Your Covered Spouse are Age 65 or over, Have Medicare and FEHB, and You are:	The Primary Payer is:
An active employee with Federal Government (including when you or a family member are eligible for Medicare solely because of a disability)	FEHB
An annuitant	Medicare
A reemployed annuitant with Federal Government	FEHB, if position not excluded from FEHB (ask your employing office)
A Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (Or your covered spouse is this type of judge)	Medicare
Enrolled in Part B only, regardless of your employment status	Medicare, for Part B services
A former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation has determined that you are unable to return to duty	FEHB
When You or a Covered Family Member Have Medicare Based on End Stage Renal Disease (ESRD) and FEHB, and:	The Primary Payer is:
Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD	FEHB
Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD	Medicare
Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision	Medicare
When You or a Covered Family Member have FEHB and:	The Primary Payer is:
Are eligible for Medicare based on disability	Medicare, if you are an annuitant. FEHB, if you are an active employee

Will My FEHB Fee-For-Service Plan Cover All My Out-Of Pocket Costs Not Covered by Medicare?

Not always. A fee-for-service plan's payment is typically based on allowable charges, not billed charges. In some cases, Medicare's payment and the plan's payment combined will not cover the full cost.

Your out-of-pocket costs for Part B services will depend on whether your doctor accepts Medicare assignment. When your doctor accepts assignment, you can be billed only for the difference between the Medicare-approved amount and the combined payments made by Medicare and your FEHB plan.

When your doctor doesn't accept assignment, you can be billed up to the difference between 115 percent of the Medicare approved amount (limiting charge) and the combined payments made by Medicare and your FEHB plan.

Medicare will pay its share of the bill and your FEHB plan will pay its share. Some services, such as medical supplies and some durable medical equipment, do not have limiting charges.

Must I Use My FEHB HMO's Participating Providers When Medicare is Primary?

If you want your FEHB HMO to cover your Medicare deductibles, coinsurance, and other services it covers that are not covered by Medicare, you must use your HMO's participating provider network to receive services and get the required referrals for specialty care.

If I Go to My FEHB HMO's Providers, Do I Have to File a Claim With Medicare

No. If needed, your HMO will file for you and then pay its portion after Medicare has paid.

Do I Have to Pay Medicare's Deductibles and Coinsurance When I Use My FEHB HMO's Doctors?

Your HMO will pay the portion not paid by Medicare for covered services.

Do I Have to Pay My FEHB HMO's Copays" Do I Have to Pay My FEHB HMO's Copays?

Usually, you will still have to pay your FEHB HMO's required copays. Some HMOs waive payment of their copays and deductibles when Medicare is primary. Check your FEHB plan's brochure for details.

For additional information about Coordination of Benefits please visit Medicare's website at www.cms.hhs.gov/COBGeneralInformation/