1. 2017 National Training Program
Medicare and Employer Group Health Plan (EGHP) Coverage
Medicare and Employer Group Health Plan (EGHP) Coverage explains some of the important facts about decisions and rules related to having EGHP coverage and making informed decisions about Medicare coverage. This training module was developed and approved by the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Federally-facilitated Health Insurance Marketplace.
The information in this module was correct as of July The CMS National Training Program provides this as an informational resource for our partners. It’s not a legal document or intended for press purposes. The press can contact the CMS Press Office at Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.

2. Session Objectives This session should help you
Recall Basic Medicare Information
Review Decisions and Timing Regarding Medicare and
Current Employer Group Health Plan (EGHP) Coverage
Retiree Coverage
A Disability (with EGHP)
End-Stage Renal Disease (with EGHP)
Distinguish Coordination of Benefits
This session should help you
Recall Basic Medicare Information
Review Decisions and Timing Regarding Medicare and
Current Employer Group Health Plan (EGHP) Coverage
Retiree Coverage
A Disability (with EGHP)
End-Stage Renal Disease (with EGHP)
Distinguish Coordination of Benefits
July 2017
Medicare and EGHP

3. What are the 4 Parts of Medicare?
Original Medicare
Part A
Hospital Insurance
Part B
Medical Insurance
Part D
Medicare prescription drug coverage
(Usually)
Medicare Advantage Part C
Medicare Prescription Drug Coverage
Medicare covers many types of services and items, and you have options for how you get your Medicare coverage. Medicare has 4 parts:
Part A (Hospital Insurance)
Part B (Medical Insurance)
Together, Part A and/or Part B are referred to as “Original Medicare.”
Part C (Medicare Advantage (MA)) is another way to get your Medicare benefits. It combines Part A and Part B, and usually Part D (prescription drug coverage). MA Plans are managed by private insurance companies approved by Medicare. These plans must cover medically necessary services.
Part D (Medicare prescription drug coverage) helps pay for outpatient prescription drugs.
July 2017
Medicare and EGHP

4. Your 2 Main Medicare Coverage Choices
Option 1: Original Medicare
Option 2: Medicare Advantage (Part C)
This includes Part A and/or Part B.
These plans are like HMOs or PPOs and typically include Part D.
Part A
Hospital Insurance
Part B
Medical Insurance
You can add:
Part D
Medicare prescription drug coverage
You can also add:
Medigap
Medicare Supplement Insurance
Part A
Hospital Insurance
Part B
Medical Insurance
Part D*
Medicare prescription drug coverage
There are 2 main ways to get your Medicare coverage, Original Medicare, or Medicare Advantage (MA) Plans. You can decide which way to get your coverage.
Option 1: Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance). You can choose to buy a Medigap policy to help cover some costs not covered by Original Medicare. You can also choose to buy Medicare prescription drug coverage (Part D) from a Medicare Prescription Drug Plan (PDP).
Option 2: MA Plans (Part C), like a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO), cover Part A and Part B services and supplies. They also may include Medicare prescription drug coverage (MA-PD). You can add a Medicare Prescription Drug Plan to a Medicare Private Fee-for-Service Plan if they don’t provide Part D coverage, and you can add it to a Medicare Medical Savings Account (MSA) Plans. You can’t add a Part D plan to a Medicare HMO or PPO plan without drug coverage.
Medigap policies don’t work with these plans. You can’t use a Medicare Supplement Insurance (Medigap) Policy to pay for out-of-pocket costs while you're enrolled in an MA Plan.
You may also be able to join other types of Medicare health plans like Medicare Cost Plans or Programs of All-inclusive Care for the Elderly (PACE), or get certain services through demonstrations and pilot programs.
July 2017
Medicare and EGHP

5. How and When Can You Enroll in Medicare?
Medicare enrollment rules and decisions vary depending on
If you get
Social Security Disability Insurance
Social Security retirement benefits, or
Railroad retirement benefits
Your age
Your other coverage, like from an employer
Medicare enrollment rules and decisions vary by your age, other coverage, (like from an employer), if you have End-Stage Renal Disease, and whether you’re receiving Social Security or Railroad retirement benefits.
If you have End-Stage Renal Disease
July 2017
Medicare and EGHP

6. Medicare Initial Enrollment Period (IEP)
7-Month Period
Months before the month you turn 65
Months after the month you turn 65
Month you turn 65 1 2 3
65th
Coverage begins first of the month you turn 65
First of next month
Delayed 2-3 months
During your IEP you can enroll/join
Part A
Part B
Part C (if you have Part A and Part B)
Part D (if you have Part A and/or Part B)
Medigap policy (if you have Part A and Part B)
No late enrollment penalties
Your first opportunity to enroll in Medicare is during your Initial Enrollment Period (IEP), which lasts 7 months. Your coverage starts based on when you enroll. If you enroll during the first 3 months of your IEP (the 3 months before the month you turn 65), your coverage will begin the first day of the month you turn 65. If you enroll the month you turn 65, your coverage will begin the first day of the next month. If you enroll in the last 3 months of your IEP (the 3 months after you turn 65), your coverage will begin 2 to 3 months after you turn 65.
If you're eligible for premium-free Part A, you can enroll in Part A once your IEP begins (3 months before you turn 65) and any month afterward. If you're not eligible for premium-free Part A, you can only enroll in Part A during your IEP or during the limited Part B enrollment periods.
July 2017
Medicare and EGHP

7. Medicare General Enrollment Period (GEP)
Starts
Jan
Continues
Feb
Ends
Mar 31
Coverage Begins
Jul 1
Period each year during which you can enroll/join
Part A
Part B
If you enroll during the GEP, from April 1-June 30, you can sign up for
Part C (if you have Part A and Part B)
Part D (if you enroll in Part B and did not qualify for premium-free Part A)
Medigap—During 6 months OEP after Medicare Part B effective date
May have late enrollment penalties
If you didn’t sign up for Part B (or premium Part A) during your Initial Enrollment Period (IEP), you can enroll during the General Enrollment Period (GEP). For most people who don’t enroll during their IEP, this is their only chance to enroll. The GEP occurs each year. It begins January 1 and ends March 31. If you enroll in the GEP, your coverage will start on July 1. This is required by law. In addition, if more than 12 months have passed since you turned 65, you'll likely have to pay a penalty that is added to your monthly Part B premium. In most cases, you’ll have to pay this penalty for as long as you have Part B.
If you aren't eligible for premium-free Part A, and you don't buy it when you're first eligible, your monthly premium may go up 10%. You'll have to pay the higher premium for twice the number of years you could’ve had Part A, but didn't sign up. This means that your monthly premiums will be higher than if you signed up during your IEP. The longer you go without the coverage, the higher the penalty.
July 2017
Medicare and EGHP

8. Medicare Special Enrollment Period (SEP)
Month 1 2 3 4 5 6 7 8
Medicare Special Enrollment Period (SEP)
Month
Retirement or EGHP Coverage Ends
8-Month period when you can enroll in
Part A
Part B
Part C (During the three months preceding Part B effective date)
Part D (During two months from loss of creditable drug coverage)
You have 6 months to buy a Medigap policy
No late enrollment penalties
If you or your spouse are still working, and you didn’t sign up for Part B (or premium Part A) during your Initial Enrollment Period (IEP), you may be able to enroll during the Special Enrollment Period (SEP). The SEP allows you to enroll after your IEP and not wait for the GEP. If eligible, you won’t have to pay a penalty, but this SEP is limited.
To be eligible, you must have group health plan coverage based on active, current employment for all the months you were eligible to enroll in Part B, but didn’t. If you're 65 or older, you must get this employer-sponsored coverage based on your or your spouse’s current employment. If you have Medicare based on disability, you can also have employer- sponsored coverage based on a member’s current employment. It's important to note that COBRA, retiree coverage, long-term workers’ compensation or Veterans Affairs coverage isn't considered active, current employment.
You have an 8-month SEP to sign up for Part A and/or Part B that starts at one of these times (whichever happens first):
The month after the employment ends
The month after group health plan insurance based on current employment ends
If you don’t enroll within the 8 months, you'll have to wait until the next GEP to enroll, you'll have a gap in your coverage, and you may have to pay a penalty.
You can enroll in Part C during the three months preceding Part B effective date. You have 2 months from loss of EGHP creditable drug coverage.
If you delayed Part B and get it during your SEP, you start your Medigap Open Enrollment Period. It lasts 6 months.
July 2017
Medicare and EGHP

9. When You Can Buy a Medigap Policy
Your one 6-month Open Enrollment Period (OEP) begins when you’re 65 or older and enrolled in Part B (some states have more generous rules)
May buy a Medigap policy any time an insurance company will sell you one
Medigap
Medicare Supplement Insurance
During Your Medigap OEP
NOT During Your Medigap OEP
Best Time Buy
May Have Preexisting Condition Waiting Period
Guaranteed Issue Period (No Medical Underwriting
May Cost More
Companies Must Sell To You any Policy They Sell for the Same Price Even if You Have a Pre-Existing Condition
Companies Can Deny Coverage
The best time to buy a Medigap policy is during your Medigap Open Enrollment Period (Medigap OEP). This period lasts for 6 months and begins on the first day of the month in which you’re both 65 or older and enrolled in Medicare Part B. If you apply during your Medigap OEP, you can buy any Medigap policy the company sells, even if you have health problems, for the same price as people with good health. If you don’t purchase a plan within your 6-month OEP, insurance companies can deny coverage based on your health conditions.
It’s also important to understand that your Medigap rights may depend on when you choose to enroll in Medicare Part B. If you’re 65 or older, your Medigap OEP begins when you enroll in Part B, and it can’t be changed or repeated. In most cases, it makes sense to enroll in Part B and purchase a Medigap policy when you’re first eligible for Medicare, because you might otherwise have to pay a Part B late enrollment penalty, and you might miss your Medigap OEP. However, there are exceptions if you have employer coverage.
While the insurance company can’t make you wait for your coverage to start, it may be able to make you wait for coverage related to a pre-existing condition. Remember, for Medicare‑covered services, Original Medicare will still cover the condition, even if the Medigap policy won’t cover your out‑of‑pocket expenses. You may buy a Medigap policy any time an insurance company will sell you one.
Some states have additional Medigap OEPs, including those for people under 65.
July 2017
Medicare and EGHP

10. Employer Group Health Plans
Coverage offered by many employers and unions
To current employees, spouse, and family members
To retirees, spouse, and family members
Retiree coverage may be employer-based Medicare Part C or Part D plans
May be fee-for-service plan or managed care plan
If you have Medicare and are offered coverage under an EGHP, usually you can choose to accept or reject the plan
Employer group health plan (EGHP) coverage is offered by many employers and unions for current employees and/or retirees. For example, the Federal Employee Health Benefits Program plan is a type of EGHP. You may also get group health coverage through your spouse’s or other family member’s employer.
If you have Medicare and are offered coverage under an EGHP, usually you can choose to accept or reject the plan. The EGHP may be a fee-for-service plan or a managed care plan, like a Health Maintenance Organization.
Employers/unions may also arrange for their Medicare-eligible retirees, spouses, and dependents to get Medicare Part C managed health care and/or Part D prescription drug coverage through employer group waiver plans.
Businesses with 50 or fewer employees can offer Small Business Health Options Program (SHOP) plans from the Health Insurance Marketplace.
July 2017
Medicare and EGHP

11. Medicare Considerations
If you have coverage through active employment
You may want to delay Part B
No penalty if you enroll while you have coverage or within 8 months of losing coverage
Delay Part A if you have a Heath Savings Account (HAS) and want to keep contributing
Stop contributions to your HSA 6 months prior to enrollment in Medicare Part A
If you don’t have coverage from active employment
Delaying Part B may mean
Higher premiums
Paying for your health care out-of-pocket
Waiting until next General Enrollment Period to enroll (January 1–March 31)
With coverage not starting until July 1
If you don’t take Part B when you’re first eligible, you’ll have to pay a premium penalty of 10% for each full 12-month period you could have had Part B but didn’t sign up for it, except in special situations. In most cases, you’ll have to pay this penalty for as long as you have Part B.
If you don’t take Part B when you’re first eligible, you may have to wait to sign up during the annual General Enrollment Period, which runs from January 1 through March 31 of each year. Your coverage will be effective July 1 of that year.
Having coverage through an employer (including federal or state employment, but not military service) or union while you or your spouse (or family member if you’re disabled) is still working can affect your Part B enrollment rights. If you or your spouse are covered through active employment, you have a Special Enrollment Period (SEP). This means you can join Part B anytime that you or your spouse (or family member if you’re disabled) is working, and covered by a group health plan through the employer or union based on that work, or during the 8-month period that begins the month after the employment ends or the group health plan coverage ends, whichever happens first. Usually, you don’t pay a late enrollment penalty if you sign up during an SEP. This SEP doesn’t apply to people with End‑Stage Renal Disease (ESRD).
You should contact your employer or union benefits administrator to find out how your insurance works with Medicare and if it would be to your advantage to delay Part B enrollment.
If you're still working or have coverage through a spouse, talk to your employer benefits coordinator to learn how enrolling in Medicare (or delaying enrollment) will affect your employer coverage. You can no longer contribute to a Health Savings Account (HSA) if you have Medicare. Talk to your company’s benefits administrator about when you should stop contributing to an HSA if you plan to sign up for Medicare. You may have to stop contributing to your HSA up to 6 months before your Medicare starts. You can withdraw money from your HSA after you enroll in Medicare to help pay for medical expenses (like deductibles, premiums, copayments). If you contribute to your HSA after you have Medicare, you could be subject to a tax penalty by the IRS. See IRS Publication 969 for more information: IRS.gov/pub/irs-pdf/p969.pdf.
July 2017
Medicare and EGHP

12. Are you… Turning 65? Over 65? Under 65 and Have a Disability?
If you aren’t getting benefits from Social Security (or the RRB) at least 4 months before you turn 65, you'll need to sign up with Social Security to get Part A and/or Part B
Over 65?
In most cases, you don't need to do anything until you (or your spouse) retire or you lose the employer coverage
Under 65 and Have a Disability?
If you aren’t getting benefits from Social Security (or the RRB) at least 4 months before you turn 65, you'll need to sign up with Social Security to get Parts A and B. However, depending on the size of the employer, you may be able to delay Parts A and B without having to pay a penalty if you enroll later. Learn more about whether you should get Parts A and B.
July 2017
Medicare and EGHP

13. How Employer Size Affects Enrollment
If you didn’t enroll when you were first eligible (during your Initial Enrollment Period), the size of the employer determines whether the employer could require you to enroll in Medicare
Employer has 20 or more employees
You can delay Part A and Part B as long as you continue to have active employment
Employer has less than 20 employees
You should sign up for Part A and Part B when first eligible
If you didn’t enroll when you were first eligible (during your Initial Enrollment Period), the size of the employer determines whether the employer could require you to enroll in Medicare
Employer has 20 or more employees
You can delay Part A and Part B as long as you continue to have active employment
Employer has less than 20 employees
You should sign up for Part A and Part B when first eligible
July 2017
Medicare and EGHP

14. What Happens If You Lose Your Job or Your Employer Coverage Ends?
Sign up for Part B and Part D as soon as you can
You have an 8-month Special Enrollment Period (SEP) to enroll in Part B to avoid a late enrollment penalty
The sooner you enroll in Part B, the sooner your coverage will start
When you enroll in Part B, it triggers your 6-month Medigap Open Enrollment Period which can’t be delayed or repeated
You only have 2 months to enroll in a Part D plan to avoid a late enrollment penalty
Your Part D coverage will start the month after the month you enroll
As soon as you lose your job or when your employer coverage ends you should sign up for Part B and Part D.
You have an 8-month Special Enrollment Period (SEP) to enroll in Part B to avoid a late enrollment penalty
The sooner you enroll in Part B, the sooner your coverage will start
When you enroll in Part B, it triggers your 6-month Medigap open enrollment period. Medicare doesn’t pay all health care costs. One way to cover the costs, or “gaps,” is to purchase a Medicare Supplemental Insurance (Medigap) policy. We‘ll discuss these policies in more detail later, but it’s important to know that when you sign up for Part B, you have a 6-month Medigap Open Enrollment Period, which gives you a guaranteed right to buy a Medigap policy. Once this period starts, it can’t be delayed or repeated.
You only have 2 months to enroll in a Part D plan to avoid a late enrollment penalty
Your Part D coverage will start the month after the month you enroll
July 2017
Medicare and EGHP

15. What if You’re Offered Consolidated Omnibus Budget Reconciliation Act (COBRA) Coverage?
When you leave your employment you may be offered to continue your group health plan coverage under the COBRA law
Employers with 20 or more employees are usually required to offer COBRA
GHP coverage under COBRA is not considered current employment for Part B SEP
Sign up for Part B within your 8-month after your GHP coverage based on current employment ends to avoid a Part B late enrollment penalty
COBRA is creditable coverage for Part D
When your employment ends and you aren’t enrolled in Part B, certain things can happen
You may get a chance to elect Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage, which continues your health coverage through the employer’s plan (in most cases for only 18 months), and probably at a higher cost to you.
You may get a Special Enrollment Period to sign up for Part B without a penalty. This period will run for 8 months and begins the month after your employment ends. This period will run whether or not you elect COBRA. If you elect COBRA, don’t wait until your COBRA ends to enroll in Part B. If you enroll in Part B after the 8‑month Special Enrollment Period (SEP), you may have to pay a late enrollment penalty and you’ll have to wait until the next General Enrollment Period to enroll.
How long does COBRA last? Assuming you pay all required premiums, COBRA coverage starts on the date of the qualifying event, and the length of the period of COBRA coverage will depend on the type of qualifying event which caused the qualified beneficiary to lose group health plan coverage.
For “covered employees,” the only qualifying event is termination of employment (whether the termination is voluntary or involuntary) including by retirement, or reduction of employment hours.  In that case, COBRA lasts for eighteen months.
If the qualifying event is the death of the covered employee, divorce or legal separation of the covered employee from the covered employee’s spouse, or the covered employee becoming entitled to Medicare, COBRA for the spouse or dependent child lasts for  36 months.     
July 2017
Medicare and EGHP

16. Creditable Drug Coverage
Current or past prescription drug coverage
Employer group health plans (EGHPs), retiree plans, Veterans Affairs, TRICARE, the Indian Health Service, and the Federal Employee Health Benefits Program
Creditable coverage pays, on average, as much as Medicare’s standard drug coverage
Plans inform yearly about whether creditable
With creditable coverage you may not have to pay a Part D late enrollment penalty
Creditable prescription drug coverage could include drug coverage from a former employer or union, TRICARE, Veterans Affairs, the Federal Employee Health Benefits Program, or the Indian Health Service. If you have other prescription drug coverage, you need information each year from your plan that tells you if the plan is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. We call this “creditable coverage.” Your plan may send you this information in a letter, post on website, or include it in its newsletter. Keep this information because you may need it if you join a Medicare drug plan later.
If you have this kind of coverage when you become eligible for Medicare, you can generally keep that coverage and won’t have to pay a penalty if you decide to enroll in a Medicare drug plan later, as long as you join within 2 months after your other drug coverage ends.
NOTE: Most Medicare Supplement Insurance (Medigap) policies that have drug coverage (were sold prior to January 1, 2006) don’t meet Medicare’s minimum standards (it’s not creditable). If you have a Medigap policy that covers drugs, you can keep your policy, but you may have to pay a penalty if you wait to join a Medicare drug plan. If you decide to join a Medicare drug plan, you’ll need to tell your Medigap insurer when your coverage starts, so your insurer can remove prescription drug coverage from your Medigap policy.
July 2017
Medicare and EGHP

17. Medicare and Retiree Coverage Considerations
Retiree plans with medical and prescription drug coverage may be offered by your former employer once you retire
May require you to enroll in Medicare Part A and Part B since Medicare pays first and your retiree plan pays second
If you delay enrolling in Part B, you’ll have to pay a late enrollment penalty and will only be able to enroll during the General Enrollment Period (Jan 1 – Mar 31)
You are responsible for Medicare’s and your retiree coverage premiums
Talk to your benefits administrator for more information
As discussed previously, people with Medicare who have employer or union retirement plans that cover prescription drugs must carefully consider their options. A person’s needs may vary from year to year based on factors like health status and financial considerations. Options offered by employer or union retirement plans can also vary each year. Each plan is required by law to annually disclose to its members how it works with Medicare prescription drug coverage.
July 2017
Medicare and EGHP

18. Medicare and Retiree Coverage Considerations (Continued)
If you lose your creditable prescription drug coverage, you have 63 days to enroll in a Part D plan without penalty
Employer/union must disclose how its plan works with Medicare drug coverage
People who drop retiree drug coverage may
Lose other health coverage
Not be able to get it back
Cause family members to lose their coverage
When deciding whether to keep or drop coverage through an employer or union retirement plan, consider these important points:
If a person with Medicare loses “creditable” drug coverage, he or she has 63 days to enroll in a Part D plan without incurring a late enrollment penalty. Contact the employer group health plan’s benefits administrator for information, including how it works with Medicare drug coverage. Creditable coverage is coverage that’s expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.
Most employer/union retirement plans offer prescription coverage comparable to Medicare drug coverage, and often generous hospitalization and medical insurance for the entire family, which is particularly important for those who are chronically ill or have frequent hospitalizations
If you drop retiree group health coverage, you may not be able to get it back. If you drop drug coverage, you may also lose doctor and hospital coverage. Family members covered by the same policy may also be affected, so any decision about drug coverage should consider the entire family’s health status and coverage needs
July 2017
Medicare and EGHP

19. When and How Can I Enroll in a Medicare Advantage Plan?
Generally during your Initial Enrollment Period
During the yearly Open Enrollment Period
October 15–December 7 each year
Coverage begins January 1
May be able to join at other times
Special Enrollment Period
Contact the plan to join
Call their telephone number
Visit their website
Use the Medicare Plan Finder at Medicare.gov
You can join a Medicare Advantage (MA) Plan when you first become eligible for Medicare, generally during your Initial Enrollment Period (IEP), which begins 3 months immediately before your first entitlement to both Medicare Part A and Part B, or during the yearly Open Enrollment Period, and in certain special situations that provide a Special Enrollment Period.
If you have Part A and enroll in Part B during the General Enrollment Period, you can join an MA Plan until June 30, so your MA coverage begins on July 1 along with your new Part B coverage.
You can only join one MA Plan at a time, and enrollment in a plan is generally for a calendar year.
You can switch to another MA Plan or to Original Medicare during the annual Open Enrollment Period, which runs from October 15 through December 7 each year.
If you belong to an MA Plan, you can disenroll to switch back to Original Medicare from January 1 through February 14 each year. If you go back to Original Medicare during this time, coverage under Original Medicare will take effect on the first day of the month following the date on which the election or change was made. If you make this change you may also join a Medicare Prescription Drug Plan to add drug coverage. Coverage begins the first of the month after the plan receives the enrollment form.
To find out which MA Plans are available in your area, visit Medicare.gov/find-a-plan to use the Medicare Plan Finder, or call MEDICARE ( ). TTY users should call
July 2017
Medicare and EGHP

20. Medicare, ESRD, and Group Health Plan (GHP) Coverage
Should I enroll in Medicare if I have End-Stage Renal Disease, am under 65 and have insurance from my or my spouse’s job?
If you have good employer insurance and don’t need Medicare to supplement your coverage
There is a period of time called a 30-month coordination period when your employer or retiree plan will pay first and Medicare will pay second
Begins when you first qualify for Medicare
Should I enroll in Medicare if I have End-State Renal Disease, am under 65 and have insurance from my spouses job? If you have good employer insurance and don’t need Medicare to supplement your coverage. There is a period of time called a 30-month coordination period when your employer or retiree plan will pay first and Medicare will pay second. It begins when you first qualify for Medicare.
July 2017
Medicare and EGHP

21. If enrollment is based solely on ESRD
Medicare, ESRD, and Group Health Plan (GHP) Coverage— Month Coordination Period
If enrollment is based solely on ESRD
Your EGHP coverage is the only payer during the first 3 months of dialysis treatments
Medicare is the secondary payer during the 30-month coordination period
Begins when first eligible for Medicare even if not enrolled
Separate coordination period each time enrolled based on ESRD
No 3-month waiting period
New 30-month coordination period if you have EGHP coverage
If you’re eligible for Medicare because you get a regular course of dialysis treatments, your Medicare entitlement will usually start the fourth month of a regular course of dialysis. Therefore, Medicare generally won’t pay anything during your first 3 months of a regular course of dialysis unless you already have Medicare because of age or disability. If you’re covered by an Group Health Plan (GHP), that plan is generally the only payer for the first 3 months of a regular course of dialysis.
Once you have Medicare coverage because of ESRD:
There’s a period when your GHP will pay first on your health care bills, and Medicare will pay second. This period is called a 30-month coordination period. However, some Medicare plans sponsored by employers will pay first. Contact your plan’s benefits administrator for more information.
There’s a separate 30-month coordination period each time you enroll in Medicare based on ESRD. For example, if you get a kidney transplant that functions for 36 months, your Medicare coverage will end. If after 36 months you enroll in Medicare again because you start dialysis or get another transplant, your Medicare coverage will start again right away. There will be no 3-month waiting period before Medicare begins to pay. However, there will be a new 30-month coordination period if you have GHP coverage.
July 2017
Medicare and EGHP

22. Enrollment Considerations— 30-Month Coordination Period
You might want Medicare during the coordination period
To pay the group health plan deductible/coinsurance
If you're getting a transplant soon
Affects coverage for immunosuppressive drugs
Coverage for living donor
Delaying Part B or Part D could mean
Waiting for applicable enrollment period to enroll
Possible penalty for late enrollment
The 30-month coordination period starts the first month you’re able to get Medicare, even if you haven't signed up yet.
Example: You start dialysis in June. The 30-month coordination period generally starts September 1 (the fourth month of dialysis even if you don’t have Medicare). Tell your providers if you have employer group health plan (EGHP) coverage during this period, so your services are billed correctly. After the 30-month coordination period, Medicare pays first for all Medicare-covered services. Your EGHP may pay for services not covered by Medicare. If you’re covered by an EGHP, you may want to delay applying for Medicare. Here are some things to consider:
If your EGHP pays all of your health care costs with no deductible or coinsurance, you may want to delay enrolling in Medicare until shortly before the 30-month coordination period ends to avoid a break in coverage. Many EGHPs will cut off primary payment after the 30th month. If you pay a deductible or coinsurance under your EGHP, enrolling in Medicare Part A and Part B could pay those costs.
If you enroll in Part A, but delay Part B, you don’t pay the Part B premium during this time. However, you’ll have to wait until the next General Enrollment Period (January 1–March 31) to enroll (coverage effective July 1) and your premium may be higher.
If you enroll in Part A, but delay Part D (Medicare Prescription Drug Coverage), you don’t have to pay a Part D premium during this time. You may have to wait until the next Open Enrollment Period to enroll (from October 15–December 7, with coverage effective January 1) and you may have to pay a lifetime monthly late enrollment penalty if you don’t have other creditable drug coverage (drug coverage that is expected to pay on average as much as standard Medicare prescription drug coverage).
July 2017
Medicare and EGHP

23. Coordination of Benefits Overview
Medicare Secondary Payer rules protect Medicare
Each type of health insurance is called a “payer”
Benefits Coordination & Recovery Center (BCRC) learns about other insurance
Identifies which is primary and ensures correct payer pays
Ensures Medicare gets repaid for any conditional payments made
When there’s more than one payer, coordination of benefits rules decide which payer pays first
There may be primary and secondary payers, and in some cases, there may also be a third payer
Medicare Secondary Payer Rules Save Medicare $9 Billion Annually.
Coordination of benefits is a way to figure out who pays first when 2 or more health insurance plans are responsible for paying the same medical claim.
Medicare eligibility data are shared with other payers, and Medicare-paid medical claims are transmitted to supplemental insurers for secondary payment. An agreement must be in place between the Centers for Medicare & Medicaid Services (CMS) Benefits Coordination & Recovery Center (BCRC) and private insurance companies for the contractor to automatically cross over medical claims. In the absence of an agreement, the person with Medicare must coordinate secondary or supplemental payment of benefits with any other insurers he or she may have in addition to Medicare.
The BCRC initiates an investigation when it learns that a person has other insurance. The investigation determines whether Medicare or the other insurance has primary responsibility for paying the person with Medicare's health care costs. The goal of these Medicare Secondary Payer (MSP) information-gathering activities is to identify MSP situations quickly, making sure responsible parties are making correct payments.
If Medicare makes a conditional payment (a payment made by Medicare for services on behalf of a person with Medicare when there is evidence that the primary plan does not pay promptly), the money must be repaid to Medicare when a settlement, judgment, award, or other payment is secured.
If you have Medicare and other health or drug coverage, each type of coverage is called a payer. When there’s more than one payer, coordination of benefits rules decide which payer pays first. The primary payer pays what it owes on your bills first, and then your provider sends the rest to the secondary payer to pay. In some cases, there may also be a third payer.
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Medicare and EGHP

24. Medicare Pays Secondary
When Does Medicare Pay?
If you have no primary other insurance
Medicare Pays Primary
If you have other insurance that must pay first (Medicare may make secondary payment if appropriate)
Medicare Pays Secondary
For services and items other health insurance is responsible for paying
Medicare Doesn’t Pay
Medicare can be the primary payer, the secondary payer, or sometimes other insurance plans should pay and Medicare shouldn’t pay at all.
Medicare may be the primary payer if you don’t have other insurance, or if Medicare is primary to your other insurance.
Medicare may be the secondary payer in situations where Medicare doesn’t provide your primary health insurance, or when another insurer is primarily responsible for paying.
Medicare may not pay at all for services and items that other health insurers are responsible for paying.
For more information, visit Medicare.gov/Pubs/pdf/02179-Medicare-Coordination-Benefits- Payer.pdf (CMS Product No ) or ecfr.gov/cgi-bin/text- idx?SID= d7a58c79361d4f698fa25219e&mc=true&node=se _120&rgn=div8 (42 C.F.R., Chapter IV, Section , Paragraph 2).
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Medicare and EGHP

25. When is Medicare the Primary Payer?
Medicare pays first for covered services when it’s your only coverage
When your other coverage source is one of these. . . OR
Medigap
Medicaid
Retiree Benefits (usually)
Medicare is the primary payer for most people with Medicare, which means Medicare pays first on their health care claims. Medicare pays first when:
Medicare is your only source of medical, hospital, or drug coverage.
Your other source of coverage is one or more of the following:
A Medicare Supplement Insurance (Medigap) policy or other privately purchased insurance policy that isn’t related to current employment. A Medigap policy covers amounts not covered by Medicare.
Medicaid and Medicare coverage (dual eligible beneficiaries), with no other coverage that could be primary to Medicare.
Retiree coverage, in most cases. To know how a plan works with Medicare, check the plan’s benefits booklet or plan description provided by the employer or union, or call the benefits administrator.
The Indian Health Service.
TRICARE (TRICARE is the U.S. Department of Defense health program for active-duty service members and their families. TRICARE for Life is the program for military retirees and their families.)
COBRA—From the Consolidated Omnibus Budget Reconciliation Act, except if you have End- Stage Renal Disease.
Indian Health Service
TRICARE for Life
COBRA*
*Except during the 30-month coordination period for people with End-Stage Renal Disease
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Medicare and EGHP

26. Medicare and Employer Group Health Plans (EGHPs)
Medicare pays first if you are
65 or older and have retiree coverage
65 or older with employer group health plans (EGHP) coverage through current employment (yours or your spouse’s) if the employer has less than 20 employees
Eligible for Medicare due to End-Stage Renal Disease (ERSD) and you have EGHP coverage when the 30-month coordination period ends, or if you had Medicare primary before you had ESRD
Under 65 with a disability and have EGHP coverage through current employment (yours or a family member’s) if the employer has less than 100 employees
Medicare pays first for people with employer group health plans (EGHPs) if they’re
65 or older and have retiree coverage
65 or older with EGHP coverage through current employment, either theirs or their spouse’s, and the employer has less than 20 employees
Under 65, have a disability, and are covered by an EGHP through current employment (either yours or a family member’s), and their employer has less than 100 employees
Eligible for Medicare due to End-Stage Renal Disease (ESRD) and they have EGHP coverage, either theirs or their spouse’s, and the 30-month coordination period has ended, and they had Medicare as their primary coverage before they had ESRD
July 2017
Medicare and EGHP

27. This Training is Provided by the
CMS National Training Program (NTP)
To view all available NTP training materials,
or to subscribe to our list, visit
CMS.gov/outreach-and- education/training/CMSNationalTrainingProgram.
Stay connected.
Contact us at or
follow us @CMSGov #CMSNTP
This training is provided by the CMS National Training Program (NTP).
To view all available NTP materials, or to subscribe to our list, visit CMS.gov/outreach-and-education/training/CMSNationalTrainingProgram.
Contact us at
Follow #CMSNTP.