Medicare Unraveled:What your Employees Need to Know

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Topics

• What is Medicare?• When should an employee enroll?• How does other coverage work with

Medicare?• Who can help?

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What is Medicare?

• Established in 1965, a federal health insurance program– Enroll through SSA– Managed by CMS

• Who can get Medicare?– People 65 years of age and older– People under 65 with certain disabilities– People with ESRD and other specific diseases

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Components of Medicare• Part A

– Inpatient hospital coverage• Part B

– Outpatient coverage (including doctors’ services, labs, tests, etc.)

• Part C (Medicare Advantage)– Combines all benefits into a single plan – Similar to an HMO or PPO

• Part D– Prescription drug coverage

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For Comprehensive Coverage

• Medicare has premiums, deductibles, and co-payments

• To offset these costs, beneficiaries may purchase additional coverage– Retiree coverage– Medigap policies– Medicare Advantage Plans (Part C)– Veterans’ benefits or TRICARE

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When Should an Employee Enroll?

• First opportunity approaching 65th birthday:

BirthdayJuly 4

Enrollment Period

Jan Feb Mar April May June July Aug Sept Oct Nov Dec

If you join during: Three months before Month of Three months after

Medicare starts: July 1 Aug 1 Oct 1 Dec 1 Jan 1

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What Parts Should an Employee Choose?

• 65 years old; continuing to work covered by EGHP (through self or spouse)– Part A– Can defer Parts B & D

• Does not apply to same-sex marriages

• 65 years or older and retiring– Parts A, B, & D– May have retiree coverage– May purchase additional coverage

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What if Part B was Deferred?

• If deferred Part B due to coverage through active employment– 8-month enrollment period – Begins at separation or loss of EGHP coverage

(whichever is first)– Enrollment beyond 8-month period may result in

a lifetime late enrollment penalty and a waiting period for coverage to begin

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What if Part D was Deferred?

• If deferred Part D due to creditable coverage– 2-month enrollment period

• Begins after loss of creditable coverage– Beneficiary must provide proof of creditable

coverage (provided by employer/EGHP)– Enrollment beyond 2 month period may result in

lifetime late enrollment penalty and a waiting period for coverage to begin

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When Should an Employee NOT Defer?

• COBRA– Not coverage through active

employment• Medical Security Program

– Health coverage through Department of Unemployment Assistance

• Active employment coverage through same-sex spouse– Federal programs cannot recognize

same-sex marriages

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How does Medicare work with other coverage?

If you Situation Pays first Pays second

Are 65 or older and covered by a group health plan because you or your spouse is still working

Entitled to MedicareGroup health plan MedicareThe employer has 20+

employees

The employer has less than 20 employees Medicare Group health plan

Have an employer group health plan after you retire and are 65 or older

Entitled to Medicare Medicare Retiree coverage

Are disabled and covered by a large group health plan from your work, or from a family member who is working

Entitled to MedicareLarge group health plan MedicareThe employer has 100+

employees

The employer has less than 100 employees Medicare Group health plan

Are 65 or over OR disabled and covered by Medicare and COBRA

Entitled to Medicare Medicare COBRA

Are covered under workers’ compensation because of a job-related illness or injury

Entitled to MedicareWorkers’ compensation for services related to workers’

compensation claim

Usually doesn’t apply. However, Medicare may make

a conditional payment.

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Medicare and HSAs

• An individual who is entitled to Medicare is no longer able to contribute to a Health Savings Account (HSA)

• Even if beneficiary only enrolls in Part A and defers Part B

• If a Medicare beneficiary has an HSA, he/she can still use existing funds in the account– Funds can even be used to pay Medicare

premiums, deductibles, or co-payments

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Who Can Help?

• Medicare– 1-800-MEDICARE– www.medicare.gov

• Social Security – 1-800-772-1213– www.ssa.gov

For questions related to Medicare benefits

For questions related to eligibility

and Parts A & B enrollment

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SHINE• Funded by Medicare, administered by

Massachusetts Executive Office of Elder Affairs in partnership with local agencies

• 13 Regional Offices and one statewide (Greater Boston Chinese Golden Age Center)• 600 certified counselors in almost every city or

town in Massachusetts• 1-800-AGE-INFO, press 3 (1-800-243-4636)

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What does a SHINE Counselor Do?• Provides free, and unbiased health insurance counseling

to Medicare beneficiaries of all ages and their caregivers– At a local site, on the phone, or via email– Home visits are available for homebound clients

• Assists clients in finding coverage that meets their needs• Answers questions regarding Medicare eligibility,

enrollment periods, and benefits• Assists with Medicare appeals and billing issues• Screens for public assistance programs

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