All FEHB plans have a coordination of benefits or double coverage provision. The purpose of this provision is to enable enrollees and covered family members to recover as much of their health care expenses as their total coverage permits, but not more than the actual charges for the care. Under the provision, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer.
Generally, if you have Medicare and you (1) are age 65 or older and (2) are not employed in the federal service, Medicare is the primary payer of your health benefits expenses, and your FEHB plan is the secondary payer.
Medicare also is the primary payer if you are age 65 or older and are enrolled in Medicare Part B medical insurance only, regardless of your employment status. If you are a federal retiree with self and family coverage and your covered spouse is age 65 or older and has Medicare coverage, Medicare is the primary payer of your spouse’s health benefits expenses unless you or your spouse are employed in the federal service and your spouse has Medicare Part A hospital insurance.
If you or a covered family member are under age 65 and are eligible for Medicare benefits on the basis of disability:
* your FEHB plan is the primary payer of health benefits expenses and Medicare is the secondary payer if you are employed in the federal service;
* Medicare is the primary payer and your FEHB, the secondary payer if you are not employed in the federal service.
Contact your local Social Security Administration office for assistance if you have any questions concerning whether your FEHB plan or Medicare is the primary payer of your or a covered family member’s health benefits expenses.
All FEHB plans will adjust any benefits payable so that they supplement rather than duplicate Medicare benefits. If Medicare is the primary payer, it generally will pay its allowable benefits in full and your FEHB plan will pay a reduced benefit as the secondary payer. The combined amount paid by both usually will equal 100 percent of covered or allowable expenses. Although 100 percent of covered or allowable expenses may be paid, there may be remaining medical expenses incurred which are not covered by either Medicare or your health benefits plan.
You are responsible for paying any noncovered expenses.
If Medicare is the primary payer, you first must submit your claim to Medicare for payment consideration. This is because your health plan cannot process a claim until after Medicare has paid any expenses they cover. Always submit the Explanation of Benefits you receive from Medicare to your FEHB plan along with your claim.