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Medicare 

 

What is Medicare?

Medicare is a federal health insurance program for the following:

  • Participants age 65 or older
  • Participants under age 65 with certain disabilities
  • Participants of any age with End-Stage Renal Disease (ESRD)

 

Medicare has the following parts to help cover specific services:

  • Medicare Part A (Hospital Insurance): Part A coverage is a premium-free program for participants with enough earned credits based on their own work history or that of a spouse at least 62 years of age (when applicable) as determined by the Social Security Administration (SSA).
  • Medicare Part B (Outpatient and Medical Insurance): Part B coverage requires a monthly premium contribution. With limited exception, enrollment is required for members who are retired or who have lost Current Employment Status and are eligible for Medicare.
  • Medicare Part D (Prescription Drug Insurance): Part D coverage is not required for plan participants in the State Employees Group Insurance Program. Medicare Part D coverage requires a monthly premium, unless the participant qualifies for extra-help assistance.

 

In order to apply for Medicare benefits, plan participants are instructed to contact their local SSA office or call 1-800-772-1213. Plan participants may also contact the SSA via the internet at www.socialsecurity.gov to sign up for Medicare Part A.

To ensure that benefits are coordinated appropriately and to prevent financial liabilities with healthcare claims, plan participants must notify the State of Illinois CMS Medicare COB Unit when they become eligible for Medicare. The Medicare COB Unit can be reached by calling 1-800-442-1300 or 217-782-7007.

State Employees Group Insurance Program Medicare Requirements

Each plan participant must contact the SSA and apply for Medicare benefits upon turning the age of 65. If the SSA determines that a plan participant is eligible for Medicare Part A at a premium-free rate, the plan participant must accept the Medicare Part A coverage.

If the SSA determines that a plan participant is not eligible for premium-free Medicare Part A based on his/her own work history or the work history of a spouse at least 62 years of age (when applicable), the plan participant must request a written statement of the Medicare ineligibility from the SSA. Upon receipt, the written statement must be forwarded to the Medicare COB Unit to avoid a financial penalty. Plan participants who are ineligible for premium-free Medicare Part A benefits, as determined by the SSA, are not required to enroll into Medicare Parts A or B.

Employees with Current Employment Status (and their applicable Dependents)

Members who are actively working and become eligible for Medicare (or have a dependent that becomes eligible for Medicare) due to turning age 65 or due to a disability (under the age of 65) must accept the premium-free Medicare Part A coverage, but may delay the purchase of Medicare Part B coverage. The State group insurance program will remain the primary insurance for plan participants eligible for Medicare due to age or disability until the date the member retires or loses Current Employment Status (such as no longer working due to a disability-related leave of absence). Upon such an event, Medicare Part B is required by the State group insurance program.

Retirees and Employees without Current Employment Status (and their applicable Dependents)

Members who are retired or who have lost Current Employment Status (such as no longer working due to a disability related leave of absence) and are eligible for Medicare (or have a dependent that becomes eligible for Medicare) due to turning age 65 or due to a disability (under the age of 65) must enroll in the Medicare Program. Medicare is the primary payer for health insurance claims over the State group insurance program. Failure to enroll and maintain enrollment in Medicare Parts A and B when Medicare is the primary insurance payer will result in a reduction of benefits under the State group insurance program and will result in additional out-of-pocket expenditures for health-related claims.

Survivors (and their applicable Dependents)

Survivors (or their dependents) who become eligible for Medicare due to turning age 65 or due to a disability (under the age of 65) must enroll in the Medicare Program. Medicare is the primary payer for health insurance claims over the State group insurance program. Failure to enroll and maintain enrollment in Medicare Parts A and B when Medicare is the primary insurance payer will result in a reduction of benefits under the State group insurance program and will result in additional out-of-pocket expenditures for health-related claims.

If you are a survivor enrolled in Medicare Part A only, it is imperative that you contact the State of Illinois CMS Medicare COB Unit to discuss the Medicare requirement.

Plan Participants Eligible for Medicare on the Basis of End Stage Renal Disease (ESRD):

Plan participants who are eligible for Medicare benefits based on End Stage Renal Disease (ESRD) must contact the State of Illinois CMS Medicare COB Unit for information regarding Medicare requirements and to ensure proper calculation of the 30-month Coordination of Benefit Period.

Each plan participant who becomes eligible for Medicare is required to submit a copy of his or her Medicare card to the CMS Medicare COB Unit.  Please send a copy of the front and back of the card to 801 S. 7th Street, P.O. Box 19208, Springfield, IL 62794-9208.  Cards may also be faxed to the Medicare COB Unit at (217) 557-3973.