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Answering your questions about Healthcare and Insurance
Human Resources and Security Specialists should use this tool to determine the correct investigation level for any covered position within the U.S. Federal Government.
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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.
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.
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.)
Medicare must pay benefits first when you are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation has determined that you're unable to return to Duty, except for claims related to the Workers' Compensation injury or illness.
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.
Your FEHB coverage will be your primary coverage until you retire.
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.
No. You will continue to pay the same premiums, unless you change to another plan or option.
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.
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.
No. If needed, your HMO will file for you and then pay its portion after Medicare has paid.
Your HMO will pay the portion not paid by Medicare for covered services.
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/