Coordination with Medicare is one of the more challenging processes for many third-party administrators. Many times they are unaware if your employees are carrying Medicare or are eligible to receive it and are not signed up for coverage.
This can be a significant and costly problem for your company when you have active employees who are also eligible for Medicare. Be careful not to assume that this only impacts your population over 65 years of age. There are many reasons that will allow those under 65 to also be eligible for Medicare. Having strong language in your plan designs will not only help your employees understand their responsibilities, but it will also help you if you identify overpayments during an audit.
Example:
“If you are eligible for or enrolled in Medicare, please read the following information carefully. If you are eligible for Medicare on a primary basis (Medicare pays before Benefits under the plan), you should enroll for and maintain coverage under both Medicare Part A and Part B. If you don’t enroll and maintain that coverage, and if we are the secondary payer as described in we will pay Benefits under the Plan as if you were covered under both Medicare Part A and Part B. As a result, you will be responsible for the costs that Medicare would have paid and you will incur a larger out-of-pocket cost.”
Comments:
The language here is good in that it has a clause that indicates that the plan will pay as secondary even if the participant doesn’t enroll. However, it does not require the participant to notify the employer and the TPA. That language would help both the employer and the TPA to better understand the Medicare status of all employees. You could also replace the word “should” with “must”. That will help communicate the importance of this process to the employees. It would also be helpful to list some of the common reasons that employees may be eligible for Medicare, and point them to some resources to better understand their eligibility. This language was also under a separate Medicare section. This is fine if the person understands that they are eligible for Medicare and decide to look in this section. But, it would be better to place it early in the document under a section most employees would read.
Considering these points will help your company reduce its health care costs and give you more leverage during a medical claim audit.
