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By Wendy Platt, CEBS, Helpline Consultant Medicare tends to be something we want to ignore and hope we won’t have to address. As more employees decide to work longer rather than retire, employers are more likely to be asked questions about the company’s health care plan and how Medicare might affect their benefits and visa versa. Given that, employers should become more informed about Medicare. This article is a very brief overview of Medicare as it is currently. Medicare Part A Part A is available for individuals who have worked less than the 40 Medicare-eligible quarters, but they must pay a premium for the coverage. Medicare Part B Eligible individuals must enroll in Part B to be covered. Generally, those who do not enroll in Part B when first eligible, will see an increase of 10% added to their monthly premium for each full 12-month period that they could have enrolled but failed to do so. Medicare Part C Medicare Part D Individuals enrolling in Part D, who have Medigap coverage, must notify their Medigap insurer and the drug coverage portion of the Medigap policy will be removed. Individuals then will be unable to get back their Medigap drug coverage. If individuals retain their Medigap drug coverage and fail to enroll in a Medicare drug plan, a penalty may be imposed if they decide to enroll later. If the employer determined that its group prescription drug plan provided benefits that are at least equal to the benefits provided under Part D, participants must have received a “Notice of Creditable Coverage” by November 15, 2005. This means that the participants in the group prescription drug plan who have creditable coverage, may delay enrolling in Part D and avoid a late enrollment fee, provided they enroll in a timely fashion when their group plan coverage ends when their employment ends. If employers determined that their drug benefit plan was not at least equal to Part D, individuals must have received a “Notice of Non-Creditable Coverage” by November 15, 2005. This means that participants must decide into which Part D plan to enroll by May 15, 2006, otherwise the penalty may apply. Sample notices for “Creditable Coverage” and “Non-Creditable Coverage” still may be found on the Centers for Medicare & Medicaid Services website at http://www.cms.hhs.gov/medicarereform/CCguidances.asp, or on our website at http://www.employersgroup.com/hrtools/index.shtml, in English and in Spanish. Employers must provide notice to the Centers for Medicare & Medicaid Services (CMS) whether or not their plan is creditable by March 31, 2006. Employers also are responsible provide follow-up submissions each year. Additional information and a link for a sample form may be found at www.cms.hhs.gov/CreditableCoverage/Downloads/Disclosure2CMSGdnc.pdf. Medicare and TRICARE Medicare and COBRA Let’s address two Medicare definitions:
Employees who reach age 65 (become eligible for Medicare), who are covered by and remain enrolled in your company’s group health plan, may continue the company’s group health coverage whether or not they are actually “entitled to” (enrolled in and covered by) Medicare. For example, you have an employee who is age 64, is covered by your company’s health plan and subsequently turns age sixty-five. That employee may retain your company’s health coverage even though that employee has become eligible for Medicare. Also, when that employee terminates employment, he or she may elect COBRA and be covered by Medicare, provided he or she is covered by Medicare prior to the COBRA election date. Conversely, COBRA coverage can be terminated if the employee becomes covered by Medicare after electing COBRA. If individuals have Part A only when the group health plan coverage ends at the time their employment ends, individuals then may enroll in Part B during a special enrollment period without having to pay a premium penalty. Individuals should enroll in Part B either at the same time they enroll in Part A or during a special enrollment period after their group health plan coverage ends when their employment ends. However, if the individual has Part A only, signs-up for COBRA and then waits until the COBRA coverage ends to enroll in Part B, there will be a penalty. There is no special enrollment period for Part B when COBRA coverage ends. Just as active employees may be covered by Medicare and still have COBRA rights at termination, they may also have other group coverage before a COBRA election and still retain COBRA rights. This is also a right for dependents who are qualified beneficiaries. Summary Plan Descriptions (SPD’s) should provide information concerning COBRA rights and eligibility. Definitions Medicaid is a joint Federal and State program that helps individuals who have low incomes and limited resources pay for their medical costs. Medicaid programs vary from state to state as states and U.S. possessions have their own State Health Insurance Assistance Programs. Medicare is a health insurance program for individuals who are age 65 or older; for some individuals with disabilities who are under age 65; and for individuals with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). Medicare deductibles and premiums are subject to change every January. Medicare Advantage is a plan offered by a private company. The company contracts with Medicare to provide Part A and Part B benefits. In many cases, the plan also offers prescription drug coverage. Types of plans offered include Health Maintenance Organizations (HMO’s), Point of Service (POS) and Preferred Provider Organizations (PPO’s). Medigap is a Medicare supplemental policy. These policies are provided by private insurance carriers to fill in the “gaps” in the original Medicare coverage. There is a penalty added to monthly premiums if individuals fail to enroll when they first become eligible. The penalty will continue as long as the individual is covered by Medicare. A Point-of-Service (POS) plan is an HMO option that permits the use of doctors and hospitals outside the plan for an additional cost. A Preferred Provider Organization (PPO) plan is a type of Medicare Advantage Plan in which an individual pays less if they use doctors, hospitals and providers belonging to the network. An additional cost is incurred for using doctors, hospitals and providers outside the network. A Qualified Medicare Beneficiary (QMB) is an individual who requires assistance with paying for Medicare services. Beneficiaries must have Part A and have limited income and resources. For those who qualify, Medicaid pays for Part A premiums, Part B premiums and Medicare deductibles and coinsurance amounts for Medicare services. Qualifying Individuals (1) (QI-1S) are those needing assistance with paying for Part B premiums. Beneficiaries must have Part A and have limited income and resources and not eligible for Medicaid. For those who qualify, the Medicaid program pays full Part B premiums only. Qualifying Individuals (2) (QI – 2S) are those who need assistance with paying for Part B premiums. Beneficiaries must have Part A and have limited income and resources and not eligible for Medicaid. Those qualifying are eligible to have Medicaid pay a percentage of Part B premiums only. A special enrollment period is for those who didn’t enroll in Part B when they were first eligible because the individual, or the individual’s spouse, was working and had group health coverage. There is no penalty provided individuals enroll during the special enrollment period immediately when group health coverage ends when their employment ends. Summary Plan Description (SPD) What should employers do? For additional information, visit www.medicare.gov, or call 1(800) MEDICARE (1-800-633-4227). To get a copy of “Medicare and You 2006,” which was a resource for this article, go to www.medicare.gov/Publications/Pubs/pdf/10050.pdf. The Department of Labor has a Frequently Ask Question (FAQ) site -- www.dol.gov/ebsa/faqs/faq_consumer_cobra.htlm. In addition, the Centers for Medicare & Medicaid Services (CMS) has two booklets: “Medicare and Other Health Benefits: Your Guide to Who Pays First, www.medicare/gov/Publications/Pubs/pdf;02179.pdf and “Medicare Basics: A guide for Caregivers,” www.medicare.gov/publications/pubs/pdf/11034.pdf. Employers Group has links to many of these sites on our website in our “Knowledge Center” under “HR Links,” then to “all HR links in alphabetical order.” |