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Does Medicare Become Your Primary Insurance

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When Can You Delay Enrolling In Medicare

Medicare For All: What Does it Actually Mean?

If you have health insurance through your or your spouses employer, and that employer has more than 20 employees, you may be able to delay enrolling in Medicare without paying a penalty. In that case, even if you did enroll in Medicare at age 65, it would be a secondary insurance and only kick in after your primary insurance paid its share of your claims. To avoid penalties after you leave your job, youll need to enroll in Medicare within eight months. 9

If your employer has fewer than 20 employees, Medicare would be your primary insurance, and you should enroll during your Initial Enrollment Period. If you miss this chance to enroll in Medicare Part B, you may face a late enrollment penalty. Every year that you delay enrollment in Medicare Part B, your premiums will go up 10% unless you or your spouse have insurance through work.10

Which Medicare Part D Prescription Drug Coverage Is Provided Under The State Of Wisconsin Group Health Insurance Program

Medicare related prescription drug coverage will be provided by Navitus Health Solutions through a self-funded, Medicare Part D Employer Group Waiver Plan called the Navitus MedicareRx plan. This plan is underwritten by Dean Health Insurance Inc., a federally-qualified Medicare contracting prescription drug plan. This affects Medicare-eligible participants covered under an annuitant contract enrolled in the State of Wisconsin Group Health Insurance Program. As required by Uniform Benefits and IYC Medicare Plus, a supplemental wrap benefit is also included to mainly provide full coverage to State members when they reach the Medicare coverage gap, also known as the “donut hole.” But the supplemental wrap benefit will also provide coverage at other times when the EGWP does not, such as during the Medicare Part D deductible and the initial coverage phases. Dean has been contracted with the Centers for Medicare and Medicaid Services since 2006, when Medicare Part D was first implemented, to offer Medicare Part D prescription drug plans to employer groups.

Your group health insurance premium already includes the cost of this benefit. There is no separate premium that needs to be paid for this Medicare Part D coverage. It is important that you read and understand the information presented on the Navitus MedicareRx plan description page. It is available online under the Available Plans page or on paper by calling ETF.

You And Your Dependents Must Have Medicare In Effect

As soon as you or your covered dependent becomes eligible for Medicare coverage that pays primary to NYSHIP , you or your covered dependent must be enrolled in Medicare Parts A and B. You must have it in effect and be entitled to receive Medicare benefits when first eligible even if you also have coverage through another employers group plan. If you or a dependent is eligible for Medicare coverage that is primary to NYSHIP, but has failed to enroll when first eligible, you may have to pay for service you receive from your HMO.

Contact your HMO to find out how your HMO coordinates with Medicare:

  • Under a Medicare+Choice Contract, you assign your Medicare benefits directly to the HMO. You will not receive any Medicare benefits if you choose to receive care outside your HMO.Under a Cost Contract or certain other arrangements, the HMO supplements your Medicare benefits. If you choose to receive treatment outside the HMO, you still qualify for Medicare benefits.
  • When an “active employee” is enrolled as a retiree’s dependentIf an active employee of the State or a Participating Employer, age 65 or over, is enrolled in NYSHIP as the dependent of a retired spouse , the employee has “retiree” coverage in NYSHIP and must enroll in Medicare when first eligible. Medicare will pay primary to NYSHIP, and the retired spouse will be eligible to receive reimbursement for the Medicare Part B premium on behalf of the active employee, unless reimbursement is received from another source.

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Medicare And Employer Coverage: Coordination Of Benefits

Lets say youre going to keep your employer coverage and also apply for Medicare. Medicare coordinates benefits with your employer coverage. Which insurance pays first? That is which is the primary payer?

The size of the employer helps determine who pays first.

  • If you work for a company that employs 20 employees or more, your employer coverage usually pays first. Medicare is the secondary payer, paying its portion for covered services your employers group health coverage did not pay. You might still have to pay a deductible and/or copayment or coinsurance amount.
  • If you work for a small company of fewer than 20 employees, Medicare usually pays first and your employer coverage is the secondary payer. Be mindful, however, of employer coverage that has a Health Savings Account feature you typically can only contribute to your HSA for the portion of the year when you arent covered by Medicare.

Do you have questions about your Medicare coverage options and how to compare costs with your employer coverage? You can call us and speak with a licensed eHealth insurance agent. You can also begin exploring your Medicare plan options right now by clicking Browse Plans on this page.

The product and service descriptions, if any, provided on these eHealth web pages are not intended to constitute offers to sell or solicitations in connection with any product or service. All products are not available in all areas and are subject to applicable laws, rules, and regulations.

If Your Or Your Spouse’s Employer Has Less Than 20 Employees And Isn’t Part Of A Multi

How does Medicare work with other insurance?

Medicare pays first. Medicare may pay second if both of these apply:

  • Your employer, which has less than 20 employees, joins with other employers or employee organizations to sponsor a group health plan , and
  • At least one or more of the other employers has 20 or more employees.

However, your plan may ask for an exception and request not to be part of a multi-employer group health plan. Check with your plan first and ask whether it will pay first or second for your claims.

I’m in a Health Maintenance Organization Plan or an employer Preferred Provider Organization Plan that pays first through my employer and I get services outside the employer plan’s network.

It’s possible that neither the plan nor Medicare will pay if you get care outside your employer plan’s network. Before you go outside the network, call your employer group health plan to find out if it will cover the service.

I have dropped employer-offered coverage.

If youre 65 or older, Medicare pays first unless these apply:

  • You have coverage through an employed spouse.
  • Your spouse’s employer has at least 20 employees.

If you don’t take employer coverage when it’s first offered to you, you might not get another chance to sign up. If you take the coverage but drop it later, you may not be able to get it back. Also, you might be denied coverage if your employer or your spouse’s employer generally offers retiree coverage, but you weren’t enrolled in the plan while you or your spouse were still working.

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Medicare And Small Group Insurance: Who Pays First

If your employer has fewer than 20 employees, then Medicare becomes primary. This means Medicare is billed first, and your employer plan will be billed second.

If you have small group insurance, its HIGHLY recommended that you enroll in both Parts A and B as soon as youre eligible. If you dont, your employers group plan can refuse to pay your claims.

Your insurance might cover claims even if you dont have Part B, but we always recommend enrolling in Part B. Your carrier can change that at any time, with no warning, leaving you responsible for outpatient costs. Youll also have to pay the late penalty because your group insurance wont be considered .

Can Medicare Be Changed From Primary Payer To Secondary Payer Depending On The Care You Need

Typically, no. Your primary and secondary coverage depends on how you get insurance, not on the type of healthcare that you need. That said, you can make Medicare your primary insurer by dropping your private insurance altogether. Or Medicare could be secondary, if you start a new job with group health insurance.

Once you end your private health insurance, youll enter Medicares 8-month special enrollment period, and youll have to sign up promptly to avoid penalties.

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What Is The Social Security Income

If you are enrolled in Medicare and your modified adjusted gross income exceeds certain limits established by federal law, you may be required to pay an adjustment to your monthly Medicare Part B and Medicare Part D plan) coverage premiums. The additional premium amount you will pay for Medicare Part B and Medicare prescription drug coverage is called the income-related monthly adjustment amount or IRMAA. Since Medicare beneficiaries enrolled in the State of Wisconsin Group Health Insurance Program are required to have Medicare Parts A, B and D, the IRMAA may impact you if you have higher income.

To determine if you will pay the additional premiums, Social Security uses the most recent federal tax return that the IRS provides and reviews your modified adjusted gross income. Your modified adjusted gross income is the total of your adjusted gross income and tax-exempt interest income.

Social Security notifies you in November about any additional premium amounts that will be due for coverage in the next year because of the IRMAA. You must pay the additional premium amount, which will be deducted from your Social Security check if it’s large enough. Failure to pay may result in Medicare terminating your coverage. The IRMAA is paid to Social Security, not the State of Wisconsin Group Health Insurance Program. It is not included in your State of Wisconsin Group Health Insurance Program premium.

If Your Or Your Spouse’s Employer Has 20 Or More Employees Then The Group Health Plan Pays First And Medicare Pays Second

How to Get the Most Out of Your Medicare Advantage Plan

If the

didn’t pay all of your bill, the doctor or

should send the bill to Medicare for secondary payment. Medicare will pay based on what the group health plan paid, what the group health plan allowed, and what the doctor or health care provider charged on the claim. You’ll have to pay any costs Medicare or the group health plan doesn’t cover.

Employers with 20 or more employees must offer current employees 65 and older the same health benefits, under the same conditions, that they offer employees under 65. If the employer offers coverage to spouses, they must offer the same coverage to spouses 65 and older that they offer to spouses under 65.

Also Check: Where Do I Send My Part B Medicare Application

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Medicare Enrollment Questions? Speak with an Agent

When Must I Apply For Medicare

State and Retirees only: Medicare Part AMost people become eligible for Medicare upon reaching age 65. Individuals who have been determined to be disabled by the Social Security Administration become eligible after a 24-month waiting period.

If you or your spouse are actively working when you become eligible, you may want to consider enrolling in Medicare Part A as it may cover hospital services if your health plan denies them. There is no premium for Medicare Part A.

Medicare Part BThe requirement to enroll in Medicare Part B coverage is deferred for active employees and their dependents until the subscriber’s termination of their Wisconsin Retirement System-covered employment, through which active employee health insurance coverage is provided.

If you have terminated employment, or are a surviving dependent, or a continuant and are eligible for coverage under the federal Medicare program, you must immediately enroll in both Part A and Part B of Medicare unless you are otherwise employed and have health insurance coverage through that employment. If you do not enroll for all available portions of Medicare upon retirement, you will be liable for the portions of your claims that Medicare would have paid beginning on the date Medicare coverage would have become effective.

If you do not receive the Medicare Eligibility Statement at least one month before your 65th birthday, please contact ETF.

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Primary And Secondary Insurance Rules

When you have two forms of health insurance coverage, your primary insurance pays the first portion of the claim up to your coverage limits. Your secondary insurance may pick up some or all of the remaining costs.

However, you still might be responsible for some cost-sharing. For example, its a mistake to think your secondary insurance will kick in and cover the deductible attached to your primary insurance. Instead, you likely will be responsible for covering the deductible.

You also may be responsible for copay and coinsurance fees.

How To Get The Most Out Of Your Combination Of Health Insurance Plans

What You Need to Know About Medicare Appeals

To make the most of the health insurance plans for which youre eligible, youll need to understand the rules and the costs of the plans. Typically, it makes sense to enroll in Medicare Part A when youre eligible, since many enrollees pay zero in premiums.

As for Medicare Part B, in some cases, youll be better off delaying your enrollment until after your employer coverage has ended, so as to avoid paying the Part B premiums. However, some employers require workers who are eligible for Medicare to sign up for it and, until they enroll, will refuse to pay for any claims.

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If Medicare Coverage Is In Effect How Do I File Medical Part B And Pharmacy Claims

If Medicare is the primary insurance, your provider must submit claims to Medicare first. Once Medicare processes the claim, Medicare will send you a quarterly Medicare Summary Notice . Exception: If you are enrolled in the IYC Medicare Advantage plan, your provider will submit claims to that plan and they will send you an Explanation of Benefits .

IYC Health Plan Medicare:Many of the health plans have an automated procedure after Medicare processes the claim, through which the provider then submits it to the health plan for processing. However, some health plans require members to submit a copy of the MSN and, in certain circumstances, a copy of the provider’s bill. You should discuss with your provider if they will bill Medicare and your health plan on your behalf. Contact your health plan for additional information.

IYC Medicare Advantage:

IYC Medicare Advantage, offered by UnitedHealthcare, allows members to seek care anywhere in the United States and its territories. The benefits are the same in- or out-of-network. You can see any provider that accepts Medicare and is willing to treat you and bill UnitedHealthcare. When you visit your provider, you must show your health plan’s card. Your provider will submit your claims directly to the health plan. To request reimbursement for a covered service charge that you paid, send your receipt and a copy of your card to the address on the back of that card. Contact UnitedHealthcare for more information.

When Is Medicare Primary Or Secondary

A number of things can affect when Medicare pays first. The following chart explains some common scenarios.2 For information on several other scenarios, check out how Medicare works with other insurance, opens new window.

retireecurrent20 or more employeescurrentless than 20 employeescurrent100 or more employeescurrentless than 100 employees

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How Does Employer Health Insurance Work With Medicare

The size of your employer will determine how your Medicare benefits will coordinate with your employer coverage. If youre aging into Medicare while working for an employer with over 20 employees, your group plan is primary and Medicare secondary.

In this scenario, most beneficiaries choose to sign up for Part A, since its premium-free for those who have paid in for sufficient quarters. If youre currently collecting Social Security Income, youll automatically be enrolled in Part A. You cant collect SSI without registering in Part A.

If you require care at a hospital, your Part A benefits will keep your costs lower. For example, if your employers group insurance has a $4,000 hospital deductible, it makes sense to enroll in Part A for a lower deductible.

For your outpatient and medication insurance, a plan from an employer with over 20 employees is creditable coverage. This safeguards you from having to pay late enrollment penalties for Part B and Part D, respectively.

Disabled Americans Covered By Large Company Ghps

Medicare 101

The Medicare Secondary Payer rules apply to many disabled Americans covered by GHPs, excluding those with Consolidated Omnibus Budget Reconciliation Act of 1985 continuation coverage. For Medicare to be a secondary payer, the GHP must come from a large company with 100+ employees.

Example: Dan is taking several months off work after struggling with health issues. His large employer has agreed his job will be there waiting for him when he feels ready to return. Medicare will become his secondary payer during this time.

Medicare Secondary Payer rules apply when a disabled American not actively working for his or her large company meets one of the following criteria:

  • Received disability payments from the company for no more than six months
  • Retains employment rights in the industry and hasnt been terminated
  • Retains employment rights and membership in the employee organization

Note that the disabled person must not be receiving Social Security disability benefits. Otherwise, the Medicare Disability Plan becomes the primary payer.

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