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. No. You will continue to pay the same premiums, unless you change to another plan or option.
MEDICARE & FEHB PRIMARY PAYER CHART
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.