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Healthcare Medicare

Frequently Asked Questions about Medicare vs FEHB Enrollment

As an active or retired Federal employee covered by both the Federal Employees Health Benefits (FEHB) Program and Medicare, you probably have had questions from time to time about how the two programs work together to provide you with your health benefits coverage. These pages contain answers to the questions we at the Office of Personnel Management are most frequently asked about FEHB and Medicare.

  • Medicare beneficiaries may enroll in Original Medicare (Parts A and B) or choose to get their benefits from an array of Medicare Advantage Plans (Part C) plan options. Depending on where you live, Part C options may include Medicare Advantage Plans that are approved by Medicare but run by private companies. Medicare Advantage plans offer Medicare Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), private fee-for-service plans (PFFS), Medicare Special Needs Plans, and Medicare Medical Savings Account (MSA) plans.

    The Medicare Prescription Drug, Improvement and Modernization Act (MMA) established a voluntary outpatient prescription drug benefit, Medicare Part D, effective January 1, 2006. Medicare enrollees are able to receive prescription drug coverage by enrolling in a Medicare Part D plan. Medicare Advantage Plans (Medicare Part C) may also offer prescription drug coverage that follows the same rules as the Medicare Part D coverage.

    Other Medicare plans include Medicare Cost Plans, demonstration/pilot programs, and PACE (Programs of All-inclusive Care for the Elderly).

  • Medicare has two new provisions: Part C (Medicare Advantage) and Part D (Medicare Prescription Drug Coverage).

    Part C: You can enroll in a Medicare Advantage plan to get your Medicare benefits. Medicare Advantage is the term used to describe the various private health plan choices available to Medicare beneficiaries.

    Part D: There is a monthly premium for Part D coverage. Most Federal employees do not need to enroll in the Medicare drug program, since all Federal Employees Health Benefits Program plans will have prescription drug benefits that are at least equal to the standard Medicare prescription drug coverage. Still, you may want to be aware of the benefits Medicare is offering, so you can help others make informed decisions. If you have limited savings and a low income, you may be eligible for Medicare's Low-Income Benefits. For people with limited income and resources, extra help in paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA). For more information about this extra help, visit SSA online at www.ssa.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

  • Original Medicare has four parts:

    Part A (Hospital Insurance) helps pay for:

    • inpatient hospital care
    • critical access hospitals
    • skilled nursing facility care
    • some home health care
    • hospice care

    Part B (Medical Insurance) helps pay for:

    • doctors' services
    • ambulance services
    • outpatient hospital care
    • x-rays and laboratory tests
    • durable medical equipment and supplies
    • home health care (if you don't have Part A)
    • certain preventive care
    • limited ambulance transportation
    • other outpatient services
    • some other medical services Part A doesn't cover, such as physical and occupational therapy

    Part C (Medicare Advantage):

    If you join a Medicare Advantage Plan you generally get all your Medicare benefits, which may include prescription drugs, through one of the following types of plans:

    • Medicare HMOs – You must get your care from primary care doctors, specialists, or hospitals on the HMO's list of network providers, except in an emergency.
    • Medicare PPO Plans – In most plans your share of plan costs is less when you use in-network primary care doctors, specialists and hospitals. Using out-of-network providers costs you more.
    • Medicare Special Needs Plans – These plans generally limit enrollment to people in certain long-term care facilities (like nursing homes); people eligible for both Medicare and Medicaid; or those with certain chronic or disabling conditions.
    • Medicare Private Fee-for-Service Plans – In these plans, you may go to any Medicare-approved primary care doctor, specialist, or hospital that will accept the terms of the private plan's payment.
    • Medicare Medical Savings Account (MSA) Plans - These plans include a high deductible plan that will not begin to pay benefits until the high annual deductible is met. They also include a medical savings account into which Medicare will deposit money for you to use to pay your health care costs. Medical Savings Account Plans do not cover prescription drugs.

    Part D (Medicare Prescription Drug Coverage)

    Under this program, private companies provide Medicare Prescription Drug Coverage and you pay a monthly premium. Federal retirees already have excellent access to health benefits coverage for drugs through participation in the FEHB Program. However, if you choose to enroll in Part D, Medicare benefits for drugs will be primary (will pay first) in most cases for FEHB enrollees. (Medicare C plans that include prescription drugs will also be primary to FEHB benefits.)

    It will almost always be to your advantage to keep your current FEHB coverage without any changes. The exception is for those with limited incomes and resources who may qualify for Medicare's extra help with prescription drug costs. Contact your benefits administrator or your FEHB Program insurer for information about your FEHB coverage before making any changes.

    It is important to note that FEHB Program prescription drug coverage is an integral part of your total health benefits package. You cannot suspend or cancel FEHB Program prescription drug coverage without losing your FEHB plan coverage in its entirety (in other words, losing coverage) for hospital and medical services which would mean you might have significantly higher costs for those services.

    Because all FEHB Program plans have as good or better coverage than Medicare, they are considered to offer creditable coverage. So, if you decide not to join a Medicare drug plan now, but change your mind later and you are still enrolled in FEHB, you can do so without paying a late enrollment penalty. As long as you have FEHB Program coverage you may enroll in a Medicare prescription drug plan from November 15 to December 31st of each year at the regular monthly premium rate. However, if you lose your FEHB Program coverage and want to join a Medicare prescription drug program, you must join within 63 days of losing your FEHB coverage or your monthly premium will include a late enrollment penalty. The late enrollment penalty will change each year but will be included in your premium each year for as long as you maintain the coverage.

    Medicare does not cover:

    • your monthly Part B premium or Part C or Part D premiums
    • deductibles, coinsurance or copayments when you get health care services
    • outpatient prescription drugs (with only a few exceptions) unless you enroll in a Part C plan which provides drug coverage or a Part D plan
    • routine or yearly physical exams
    • custodial care (help with bathing, dressing, toileting, and eating) at home or in a nursing home
    • dental care and dentures (with only a few exceptions)
    • routine foot care
    • hearing aids
    • routine eye care
    • health care you get while traveling outside of the United States (except under limited circumstances)
    • cosmetic surgery
    • some vaccinations
    • orthopedic shoes

    Complete Medicare benefits information can be found in the Centers for Medicare and Medicaid Services publication, Medicare & You handbook which can be found on the Medicare website (www.medicare.gov).

  • You are eligible for Medicare if you are age 65 or over. Also, certain disabled persons and persons with permanent kidney failure (or End Stage Renal Disease) are eligible. You are entitled to Part A without having to pay premiums if you or your spouse worked for at least 10 years in Medicare-covered employment. (You automatically qualify if you were a Federal employee on January 1, 1983.) If you donï't automatically qualify for Part A, and you are age 65 or older, you may be able to buy it; contact the Social Security Administration. You must pay premiums for Part B coverage, which are withheld from your monthly Social Security payment or your annuity. You must be enrolled in both Medicare Parts A and B before you can enroll in Part C. You must be enrolled in either Part A or Part B before you can enroll in Part D. The cost of any additional premium will vary depending on the Part C or Part D plan that you select.

  • Generally, plans under the FEHB Program help pay for the same kind of expenses as Medicare. FEHB plans also provide coverage for emergency care outside of the United States which Medicare doesn't provide. Some FEHB plans also provide coverage for dental and vision care. Medicare covers some orthopedic and prosthetic devices, durable medical equipment, home health care, limited chiropractic services, and some medical supplies, which some FEHB plans may not cover or only partially cover (check your plan brochure for details).

  • If you are entitled to Part A without paying the premiums, you should take it, even if you are still working. This may help cover some of the costs that your FEHB plan may not cover, such as deductibles, coinsurance, and charges that exceed the plan's allowable charges. There are other advantages to Part A, such as (if you also enroll in Part B,) being eligible to enroll in a Medicare Advantage Plan.

  • Yes, you may change your FEHB enrollment to any available plan or option at any time beginning 30 days before you become eligible for Medicare. You may use this enrollment change opportunity only once. You may also change your enrollment during the annual Open Season, or because of another event that permits enrollment changes (such as a change in family status).

  • Once Medicare becomes the primary payer, you may find that a lower cost FEHB plan is adequate for your needs, especially if you are currently enrolled in a plan's high option. Also, some plans waive deductibles, coinsurance, and copayments when Medicare is primary.

  • When you enroll in a Medicare Advantage plan, you may not need FEHB coverage because the Medicare Advantage plan will provide you with many of the same benefits. You should review the Medicare Advantage Plan benefits carefully before making a decision to suspend or cancel FEHB coverage. You should contact your retirement system to discuss suspension and reenrollment.

  • If you provide documentation to your retirement system that you are suspending your FEHB coverage to enroll in a Medicare Advantage plan, you may reenroll in FEHB if you later lose or cancel your Medicare Advantage plan coverage. However, you must wait until the next Open Season to reenroll in FEHB, unless you involuntarily lose your coverage under the Medicare Advantage plan (including because the plan is discontinued or because you move outside its service area). In this case, you may reenroll from 31 days before to 60 days after you lose the Medicare Advantage plan coverage, and your reenrollment in FEHB will be effective the day after the Medicare Advantage plan coverage ends (or ended).

  • During the fall of each year, you will receive a copy of the Medicare & You handbook. It is also available by calling 1-800-MEDICARE (1-800-633-4227) or TTY 1-877-486-2048, or at www.medicare.gov/publications/pubs/pdf/10050.pdf. The Medicare & You handbook has information on Medicare Parts A & B; Medicare Advantage Plans (Part C); Medicare Prescription Drug Coverage (Part D); Help for People with Limited Income and Resources; and Joining and Switching Plans. The Medicare website (www.medicare.gov) contains the handbook and other information about Medicare. If you do not have a personal computer, your local library or senior center may be able to help you access this website. You should contact your retirement system before making any change to your coverage, especially if you are considering suspending your FEHB coverage to enroll in a Medicare Advantage Plan. If you are a CSRS or FERS annuitant, you may call OPM's Retirement Information Office at 1-88USOPMRET (1-888-767-6738) or 202-606-0500 from the metropolitan Washington area, or you may write to:

    Office of Personnel Management
    Retirement Operations Center
    P.O. Box 45
    Boyers, PA 16017-0045

    Other useful publications, such as the Guide to Health Insurance for People with Medicare, are also available at the Medicare number (1-800-633-4227) or from your State Health Insurance Assistance Program (SHIP) counseling office. The SHIP counselors in your state are also available by telephone or sometimes as a walk-in resource if you would like more personalized attention. You can find SHIP counseling office telephone numbers in the Medicare & You handbook or on the Medicare website at www.medicare.gov/contacts/static/allStateContacts.asp.

    Your FEHB plan brochure provides specific information on how its benefits are coordinated with Medicare. Some HMOs participating in the FEHB are structured to provide more comprehensive coverage if you enroll in both their HMO and their Medicare Advantage plan.

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