Medicare and Employer Coverage

Understanding How Medicare Works

Medicare is a federal health insurance program that provides coverage for people who are 65 or older, as well as for people under 65 with certain disabilities or health conditions. The program is divided into several parts:

• Medicare Part A: Hospital insurance that covers inpatient care, hospice care, and some home health care services.
• Medicare Part B: Medical insurance that covers doctor visits, outpatient care, and preventive services. Original Medicare pays 80% if you have Parts A&B.
• Medicare Part C: Also known as Medicare Advantage, these are plans offered by private insurance companies approved by Medicare. They typically include all the benefits of traditional Medicare, but also often include additional benefits like vision, dental, and hearing coverage.
• Medicare Part D: Prescription drug coverage that helps pay for the cost of prescription drugs.

When to Apply for Medicare

If you’re approaching age 65 and you or your spouse have paid Medicare taxes for at least 10 years, you’re eligible for Medicare. You can enroll in Medicare during a seven-month period that starts three months before the month you turn 65 and ends three months after the month you turn 65. If you’re not yet receiving Social Security or Railroad Retirement Board benefits when you turn 65, you’ll need to sign up for Medicare through Social Security.

If you miss your initial enrollment period, you may have to pay a late enrollment penalty. However, if you’re still working and covered by your employer’s health insurance plan when you turn 65, you may be able to delay enrolling in Medicare without penalty.

Employer Health Coverage and Medicare

If you’re still employed and receiving health insurance coverage through your employer, it’s important to understand how your employer health benefits works with Medicare. The rules for Medicare and employer coverage can differ based on the size of the company you work for.

For those working in companies with less than 20 employees, Medicare is the primary payer. This means that you must enroll in both Medicare Part A and Part B to be covered by your employer’s plan. If you don’t, you may find yourself exposed and uninsured, or at least partially uninsured, should you need any medical attention.

If you work for a company with more than 20 employees, your employer’s coverage is usually the primary payer, and you may be able to delay enrolling in Medicare without penalty. However, it’s important to carefully compare the benefits and costs of Medicare coverage and employer coverage to determine the best option for your healthcare needs.

Medicare Advantage Plan and Employer Health Coverage

If you’re eligible for Medicare, you have the option to choose between traditional Medicare and Medicare Advantage, which is offered by a private insurance company approved by Medicare. A Medicare Advantage Plan typically include all the benefits of traditional Medicare, but also often include additional benefits like vision, dental, and hearing coverage.

If you have employer health insurance coverage, it’s important to carefully compare the benefits and costs of both traditional Medicare and Medicare Advantage plans before making a decision. Be sure to review your employer’s health insurance plan and the Medicare Advantage plan’s network of providers to ensure you are getting the best coverage for your healthcare needs. A Medicare Supplement Plan should also be considered. It covers the gap that Original Medicare does not cover. A Medicare Supplement Plan is our choice for best Medicare and Employer coverage.

Health Savings Account and Employer Health Insurance

Health Savings Accounts (HSAs) are another aspect to consider when it comes to navigating Medicare and employer health coverage. HSAs are tax-advantaged savings accounts that can be used to pay for medical expenses, including Medicare premiums and out-of-pocket costs.

If you have an HSA through your employer insurance, you can continue to contribute to it even after you enroll in Medicare, if you have a high-deductible health plan. However, once you enroll in Medicare benefits, you can no longer contribute to the account.

It’s important to note that while you cannot contribute to a Health Savings Account while on Medicare, you can still use the funds in the account to pay for eligible medical costs, including Medicare premiums and deductibles. Additionally, if you delay enrolling in Medicare and continue to contribute to your HSA, you can use the funds in the account to pay for qualified medical expenses until you enroll in Medicare. Having both Medicare and an HSA really is the best of both worlds.

Enrolling in Medicare with Employer Coverage

If you’re still employed and covered by your group health plan coverage when you become eligible for Medicare, you may be able to delay enrolling in Medicare without Understanding the relationship between Medicare and employer coverage is essential in ensuring you have the right coverage when you need it.

If you or your spouse are still working and are eligible for employer health coverage, there are several factors to consider when deciding whether to enroll in Medicare.

One key consideration is the size of the employer. If you work for an employer with fewer than 20 employees, Medicare is considered the primary payer, meaning you must enroll in both Part A and Part B to be covered by your employer’s plan. If you do not enroll, you could find yourself exposed and uninsured, or at least partially uninsured, should you need medical attention.

On the other hand, if you work for an employer with 20 or more employees, your employer’s health plan is considered the primary payer, and you have the option to enroll in Medicare as a secondary payer. In this case, Medicare can provide additional coverage and help reduce out-of-pocket expenses for things like deductibles, copayments, and coinsurance.

If you decide to enroll in Medicare while you’re still covered by your employer’s health plan, it’s important to know how the two types of coverage work together.

For example, if your employer’s plan is the primary payer, it will pay first, and Medicare will pay second. However, Medicare may not pay for all services that your employer’s plan doesn’t cover, and you may still have some out-of-pocket costs.

In some cases, you may be better off delaying enrollment in Medicare Part B, which covers doctor visits and other outpatient services, if your employer’s health plan already provides this coverage. You can enroll in Part A, which covers hospital stays and other inpatient care, without any penalty, if you or your spouse are still working and covered by your employer’s plan.

It’s also important to understand that if you do not enroll in Medicare Part B when you are first eligible, you may face a late enrollment penalty. This penalty can increase your monthly premium for Part B for the rest of your life, so it’s important to enroll in a timely manner. We advise our clients to make sure they are enrolled properly for their Medicare Enrollment.

If you have retiree insurance from a former employer, it’s also important to understand how these benefits work with Medicare. Retiree health benefits are often considered the primary payer, and Medicare is the secondary payer. If you are retired and have retiree health benefits, you will need to enroll in both Medicare Part A and Part B to ensure you have complete coverage.

Another factor to consider when deciding whether to enroll in Medicare is prescription drug coverage. If you have prescription coverage through your employer’s health plan, it’s important to determine whether this coverage is considered “creditable.”

Creditable coverage means that your drug coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.

Top 5 Differences between group coverage (employer coverage) and Medicare:

Eligibility: Employer coverage is typically offered by employers to their employees and their dependents, while Medicare is a government-run health program that is available to eligible individuals who are 65 years old or older, or to those who have certain disabilities or chronic conditions.

1. Cost: The cost of group coverage is typically shared between the employer and employee, with the employer often subsidizing a portion of the premium. In contrast, Medicare is funded by the federal government and has its own costs, including premiums, deductibles, and co-payments. However, Medicare coverage can be less expensive than group coverage for some people, particularly those with high healthcare costs.
2. Benefits: Group coverage and Medicare have different benefit structures. Group coverage often offers a range of benefits, including medical, dental, and vision coverage, as well as other benefits like disability insurance and life insurance. Medicare, on the other hand, offers different parts with different coverage – e.g. Part A covers hospital care, Part B covers medical services, and Part D covers prescription drugs.
3. Provider networks: A Group Health Plan often has a specific network of healthcare providers that employees can use, while Medicare has a much larger network of providers that accept Medicare. However, certain Medicare plans, like Medicare Advantage, may have limited networks.
4. Coverage limitations: Employer Insurance may have limitations on what types of medical procedures or treatments are covered, while Medicare has standardized benefits that must be covered by law. However, Medicare may have limitations on the frequency or number of certain types of care, and some procedures or treatments may require prior authorization from Medicare.
5. Coverage limitations: Group coverage may have limitations on what types of medical procedures or treatments are covered, while Medicare has standardized benefits that must be covered by law. However, Medicare may have limitations on the frequency or number of certain types of care, and some procedures or treatments may require prior authorization from Medicare.

About Part D (Prescription Drug Coverage)

If your employer’s drug plan is not considered creditable, you may want to enroll in Medicare Part D, which is Medicare’s prescription drug coverage. If you do not enroll in Medicare Part D when you are first eligible, you may also face a late enrollment penalty.

In summary, understanding how Medicare and employer health coverage work together is crucial for making informed decisions about your healthcare coverage. Factors to consider include the size of your employer, whether your employer health insurance covers the same services as Medicare, and whether or not you have retiree health benefits or prescription drug coverage.

In conclusion:

If you’re not sure what to do or need more information, it’s always a good idea to speak with a Medicare expert or your employer’s benefits administrator to get the information you need to make the best decision for your healthcare needs. Employer coverage and employer insurance doesn’t have to be difficult. The team at FHI are experts on Medicare and Employer coverage so let us help you today!