Medicare Primary, FEHB Secondary

somarco

GA Medicare Expert
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Atlanta
Talked with a guy (diabetic type 1 with CGM) who said Medicare was primary, FEHB secondary. When insulin is submitted to Medicare under Part B they deny the claim. But his FEHB pays anything denied by Medicare.

I don't think I have run into anyone (yet) who has Medicare and FEHB but found it odd the FEHB pays claims denied by Medicare. He is quite adamant in his statement but if this is true, why even bother with Medicare B? Why not pass Go and collect $200?
 
Most postal emoloyees just keep fehb and not elect part b as you know when they retire. I have seen 3 clients this year that decided to pass on b and keep fehb. I would think most insulin would be covered under D and his prescription plan with fehb would pay. I have not come across a situtation where insulin is covered under b,. But im sure this can happen. Does he have a stand alone pdp or ma plan? Anyway people take B all the time when they dont need it. U r right he should not be taking b. I would ask 2 see all his cards.
 
Insulin may be covered under B if you have a pump.

Guy claims he has original Medicare A & B, and FEHB as his "supplement". Can't say if he has D or not. The issue was him saying Medicare was primary and when they deny the insulin claim FEHB pays it @ 100%.

I have never run into this before. Don't work with any retired CERS or FERS clients to my knowledge. Seems they usually know all the answers already.

No reason to pursue this with him. Just wondered if he was correct about full FEHB coverage on a Medicare denied claim.
 
I looked at the rules for FEHB and Medicare. Confusing to say the least considering there are dozens of plans depending on your state.

This guy won't buy anything from me. He already knows it all. So I am not trying to convince him of anything.

Just asking because it is odd that a plan would pay a claim denied by Medicare. Group plans have similar medical necessity wording that you can find in Medicare. If Medicare denies it they usually do the same.
 
FEHB covers non-pump insulin under its drug benefit. FEHB acts as their Part D and Medigap when enrolled in Part B. Generally, the medical service has to be covered under Parts A/B/D to be covered by FEHB. It's no different than Crestor being denied by Part B because it should have been submitted to Part D (or its equivalent like FEHB).

Many federal retirees do choose FEHB only but incur cost sharing expenses. Those who choose both either:

1) Do not understand Part B is optional for them;
2) Want the lower cost sharing (which may not offset the Part B premium);
3) Fear being subject to the Part B LEP should the rules change in the future to require Part B enrollment.
Do FEHB Plans and Medicare Cover the Same Types of Expenses?

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).

Reference: https://www.opm.gov/healthcare-insurance/healthcare/medicare/medicare-vs-fehb-enrollment/
 
Thanks for the response and clarity. I figured you would know and hoped you would pop in.
 
FEHB covers non-pump insulin under its drug benefit. FEHB acts as their Part D and Medigap when enrolled in Part B. Generally, the medical service has to be covered under Parts A/B/D to be covered by FEHB. It's no different than Crestor being denied by Part B because it should have been submitted to Part D (or its equivalent like FEHB).

Many federal retirees do choose FEHB only but incur cost sharing expenses. Those who choose both either:

1) Do not understand Part B is optional for them;
2) Want the lower cost sharing (which may not offset the Part B premium);
3) Fear being subject to the Part B LEP should the rules change in the future to require Part B enrollment.

I would hope if the rules did change that people with FEHB and no Part B wouldn't be subject to the Part B LEP, but you never know with the government.
 
Just out of curiosity, as I've run into a few FERS people recently, is there a scenario where they are better off from a dollars perspective to drop FEHB, pay the Part B premium and deductible? Say in the case of a $0 premium MAPD? I understand the MOOP risk but if they are struggling to make ends meet it seems like that could be cheaper as some of the FEHB premiums can be hefty. I'm sure this gets down to the specifics of which FEHB plan they are in. I wouldn't ever put someone into a less-rich plan unless they truly can't afford and it sounds like leaving FEHB would be a downgrade in most instances but wanted to know if there are scenarios that it makes sense? Thanks.
 
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