Click here to skip navigation
OPM.gov Home  |  Subject Index  |  Important Links  |  Contact Us  |  Help

U.S. Office of Personnel Management - Ensuring the Federal Government has an effective civilian workforce

Advanced Search

Insurance Services Programs

Federal Employees Health Benefits Program

Medicare and FEHB FAQs


 

Coordination of Medicare and FEHB Benefits

Q. Does My FEHB Plan or Medicare Pay Benefits First?

A. Medicare law and regulations determine whether Medicare or FEHB is primary (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 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.

Q. When is My FEHB Plan the Primary Payer?

A. Your FEHB Plan must pay benefits first when you are an active Federal employee or reemployed annuitant and either you or your covered spouse have Medicare, unless 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.

Q. When is Medicare the Primary Payer?

A. Medicare must pay benefits first when you are an annuitant, and either you or your covered spouse have Medicare. This includes when you or your covered spouse are 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.

Medicare must pay benefits first when you are receiving Workers' Compensation and the Office of Workers' Compensation has determined that you're unable to return to duty.

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

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

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

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

A. 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.

A. 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

Medicare, except for claims related to the Workers' Compensation injury or illness

 
 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

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

A. Not always. A managed fee-for-service plan's payment is typically based on reasonable and customary charges, not on 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 115 percent of the Medicare-approved amount (the "limiting charge") when your FEHB plan's payment and Medicare's payment don't cover the full cost.

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

A. 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.

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

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

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

A. No. Your HMO will pay the portion not paid by Medicare for covered services.

A. 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.