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My husband owns a small business (less than 20 employees). He is over 75 and has been on Medicare part A for over 10 years and had never considered part B because he has group health insursnce through his business. I have just begun looking into this and am finding the info confusing. I have some questions that I am hoping someone can answer.
1. I read that if one is 65 + and has insurance through an employer with less than 20 employees, they are required to sign up for part B and that even if they don’t, the government considers Medicare their primary insurer for outpatient coverage and that their insurer through the employer can deny claims that would typically picked up by Medicare B if they were enrolled.
I read that the employer (my husband) decides if an employee is required to sign up for part B.
Can anyone clarify these issues?
3. Regarding part B penalty for late enrollment, how do we find out if his group plan wu as lifted Hume for special enrollments to avoid fees which would be quite high at this point?
4. Regarding his current insursnce, he currently pays ~ $800.00 per month for a high deductible ($10,000 per year) PPO. Assuming that he is eligible for plan B without penalties/additional premiums, is there any advantage to him keeping his current plan?
I mentioned in my post that my husband had never looked into part B until now. His insurance had been much less expensive in the past. I am looking for answers to my questions.
My husband owns a small business (less than 20 employees). He is over 75 and has been on Medicare part A for over 10 years and had never considered part B because he has group health insursnce through his business. I have just begun looking into this and am finding the info confusing. I have some questions that I am hoping someone can answer.
1. I read that if one is 65 + and has insurance through an employer with less than 20 employees, they are required to sign up for part B and that even if they don’t, the government considers Medicare their primary insurer for outpatient coverage and that their insurer through the employer can deny claims that would typically picked up by Medicare B if they were enrolled.
2. I read that the employer (my husband) decides if an employee is required to sign up for part B.
Can anyone clarify these issues?
3. Regarding part B penalty for late enrollment, how do we find out if his group plan wu as lifted Hume for Atspecial enrollments to avoid fees which would be quite high at this point?
4. Regarding his current insursnce, he currently pays ~ $800.00 per month for a high deductible ($10,000 per year) PPO. Assuming that he is eligible for plan B without penalties/additional premiums, is there any advantage to him keeping his current plan?
Thank you, any help will be greatly appreciated.
1. This is essentially true - he needs to talk to his insurer.
2. Only if insurer allows or your plan is self-funded and hubby makes the administration rules. Again, talk to the insurer. Many plans have Medicare carve-outs, although at $800/mo. this wouldn't appear to be the case. Talk to your insurer.
3. Appears from Medicare.gov late enrollment penalty would not apply (this is different from years past, so it appears CMS may have changed the rules w/our changing economy) - although penalty might still apply w/Part D. Again, check w/insurer that Part D is creditable. We do have a poster who says he is paying a late-enrollment penalty for Part B b/c his employer did not have more than 20 employees. But that penalty is no longer mentioned on the Medicare website, although I clearly remember it had been years past. The key a few years ago was entire employer plan had to be "creditable" - not just the drug plan.
4. Costs. Medicare premium $170, Medigap $250 (high est. - varies by state), Part D $50 - total apprx. $500 with $233 Part B deductible (no copays w/Medigap Plan G) and Part D copays (deductible for Part D not more than $455/varies by plan) - total $500/mo. A way better deal than $800 w/$10k deductible. Of course, if his income is high, his Part B premium might be higher - brackets shown here:
Know that if hubby decides to enroll in Part B, the six-month clock on Medigap guaranteed issue period starts - i.e., no health underwriting required. Which means if he purchases a Medigap long after Part B enrollment, depending on your state, he could be denied or charged a higher premium.
I am the poster who pays a penalty because I didn’t have a large group plan. If Medicare change their policy about that does it only apply to new enrollments? The reason is that for these situations, Medicare is primary.
OP if he qualifies for a Special Enrollment Period (SEP) he won’t be penalized.
I am the poster who pays a penalty because I didn’t have a large group plan. If Medicare change their policy about that does it only apply to new enrollments? The reason is that for these situations, Medicare is primary.
OP if he qualifies for a Special Enrollment Period (SEP) he won’t be penalized.
After I posted last night, for further clarification, I wrote SCGamecock who has an inordinately detailed knowledge of Medicare. He replied, saying your issue is b/c you are under 65.
Here is his response to my comments on this thread and your situation:
Quote:
Originally Posted by SCGamecock
I agree with your response in the thread with a couple of clarifications. In bullet #4, it is unclear if the current $800/month Group Health Plan (GHP) is a family plan. A single plan cannot have a $10k deductible unless it's grandfathered. The Medicare costs may need to be doubled if the spouse is 65+.
There have been no changes regarding GHPs. "Creditable" only refers to Part D drug coverage. If the GHP is creditable, he will have received letters from the plan administrator each Sept/Oct for the past 10 years stating such. If he has those letters, or can get the plan to provide copies, he will not owe a Part D LEP.
For Part B, it only needs to be a GHP. "Creditable" has never been a criteria. The 20 employee guideline only applies to primary/secondary coverage.
There is no Part B LEP [late enrollment penalty] for those 65+ with any continuous GHP.
Only persons under 65 must have a large GHP to avoid the LEP. Search for 'large' on the form below.
Member dfk747 has responded to the thread saying they pay Part B LEP. I found this post confirming they're on SSDI, so yes it must be large GHP for them.
If the creditable drug letters are clearly from a GHP, the SSA offices in my area take this in lieu of L564 for persons 65+, so that may be where the confusion lies. I hope this helps.
So, OP, there is no late enrollment penalty (and never was) for those 65and older covered by a Group Health Plan even if under 20 employees - and your Medicare costs may double if this plan covers you and hubby. Even so, elimination of the $10K deductible is huge.
Last edited by Ariadne22; 02-12-2022 at 02:33 PM..
After I posted last night, for further clarification, I wrote SCGamecock who has an inordinately detailed knowledge of Medicare. He replied, saying your issue is b/c you are under 65.
Here is his response to my comments on this thread and your situation:
So, OP, there is no late enrollment penalty (and never was) for those 65and older covered by a Group Health Plan even if under 20 employees - and your Medicare costs may double if this plan covers you and hubby. Even so, elimination of the $10K deductible is huge.
Thanks for looking into that. I was starting to wonder if that was the case. So, my warnings only apply to under 65. That’s very interesting.
Thank you for the responses. We will speak with his plan administrator. My husband’s group insurance plan is new as of July 2021. The previous one is no longer offered and was much more reasonable. When he became Medicare eligible, over 10 yrs ago, he told the administrator that he did not want to enroll in Medicare part B, although the increase in insursnce rates is causing us to look at this more closely. His plan is an individual plan and the info that he has says 10k deductible. He will review it again; perhaps this deductible amount is for hospitalization.
He will review it again; perhaps this deductible amount is for hospitalization.
Extremely unlikely. As SCGamecock said, it appears both of you are covered under this plan - the high deductible being a clue. Plans these days have individual or family deducitibles - which must be met via labs, dr. visits, hospitalizations - the entire panorama of medical services - before plan starts paying.
When the plan does pay, insured is still usually responsible for between 10%-20% of the negotiated rate (between insurer and provider) until maximum out-of-pocket is met. Chances are your plan's OOP is higher than $10k. Do you know your plan's OOP? The OOP (which includes the $10k), is your overall exposure. OOP is probably in the area of $16k I'm guessing.
There is no exposure of this magnitude with Medicare/Medigap - unless one has a service not covered by Medicare.
At best, w/Medicare/Medigap, deductible is $233 - thereafter between Medicare/Medigap Plan G, all costs are paid 100%.
A less expensive, far more cost-effective form of Medigap for the healthy is the high-deductible Medigap G - which many here have. Premiums can be up to 70% less than a full Medigap, depending on state. A recent thread on the issue, here:
Thank you for the responses. We will speak with his plan administrator. My husband’s group insurance plan is new as of July 2021. The previous one is no longer offered and was much more reasonable. When he became Medicare eligible, over 10 yrs ago, he told the administrator that he did not want to enroll in Medicare part B, although the increase in insursnce rates is causing us to look at this more closely. His plan is an individual plan and the info that he has says 10k deductible. He will review it again; perhaps this deductible amount is for hospitalization.
There is huge confusion your plan administrator can help clear up. With an employer plan maybe it would still be primary & Medicare secondary. You can end up in a situation where a bill gets bounced from insurance to Medicare to see who pays first. There is also a situation where the doctor charges, Medicare allows, maybe insurance pays. Don't know if you can be billed directly by doctor before this gets cleared.
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