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This publication is written in plain language for use by members of the Ohio Public Employees Retirement System. It is not intended
as a substitute for the federal or state law, namely the Ohio Revised Code, the Ohio Administrative Code, or the Internal Revenue
Code, nor will its interpretation prevail should a conflict arise between it and the Ohio Revised Code, Ohio Administrative Code,
or Internal Revenue Code. Rules governing the retirement system are subject to change periodically either by statute of the Ohio
General Assembly, regulation of the Ohio Public Employees Retirement Board, or regulation of the Internal Revenue Code. If you
have questions about this material, please contact our office or seek legal advice from your attorney.
This document reflects information as of the date listed herein. There is no promise, guarantee, contract or vested right to access to
health care coverage or a premium allowance. The board has the discretion to review, rescind, modify or change the health care plan
at any time.
Photography courtesy Thinkstock.com
Medicare Guide
(Revised January 2015)
2015
HealthCare
Medicare Guide
For participants in the
OPERS health care plan
Inside this Guide
Medicare Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
OPERS and Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
OPERS Medical and Prescription Drug Plans. . . . . . . . . . . . . .9
OPERS Medicare Connector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
2015 OPERS Medicare Guide
This guide will provide you with some basic
knowledge about Medicare, your OPERS group
Medicare plan administered by Humana and an
update of what’s to come in 2016 with the OPERS
Medicare Connector.
When you become eligible for Medicare, the
federal government’s health insurance program
administered by The Centers for Medicare &
Medicaid Services (CMS), it will be vital for you
to examine how your Medicare health insurance
benefits work with the OPERS Health Care Plan.
At OPERS, we understand that making decisions
about your health care can be a complex and
important process. We have designed this
publication to help you make the connection
between Medicare and OPERS and to help you
navigate the Medicare enrollment process with
Social Security.
1
Medicare is
federal health insurance
for people age 65 and older, under
age 65 with certain disabilities,
and any age with End-Stage Renal
Disease (permanent kidney
failure requiring dialysis or a
kidney transplant).
Medicare Basics
Medicare costs vary depending on your plan,
coverage and the services you use. For many years,
Medicare had two major parts: Part A for hospital
insurance and Part B for out-patient medical
insurance. These parts are known as Original
Medicare. Two additional parts (Parts C and D) were
added later. Below is a high-level view of each of
the four parts that make up the Medicare program:
ORIGINAL
MEDICARE
3
Medicare Basics
Medicare
Advantage
and Medigap
(Medicare
Supplement)
Plans
Medicare Advantage and Medigap
(Medicare Supplement) plans provide
additional coverage beyond Original
Medicare. Understanding the differences
between the two plans is important so
you can select the plan that best suits
your lifestyle in the future.
Medicare Advantage plans are private
health insurance plans that replace
Original Medicare and must provide
the same level of coverage that Original
Medicare does. They also provide
additional coverage options. Medigap
plans are also private health insurance
plans, however they are designed to
supplement Original Medicare, or fill in
the “gaps” where Medicare Parts A and
B leave an individual uninsured.
4
2015 OPERS Medicare Guide
Medicare Basics
Medicare
Enrollment
The Social Security Administration allows you to
enroll in Medicare Part A and Part B only at the
following times:
Initial Enrollment Period
• Your initial enrollment period for Medicare
Parts A and B begins three months before and
ends three months after your 65th birthday.
• If you are eligible for Medicare due to a
qualifying disability or End-Stage Renal
Disease, your initial enrollment period depends
on the date your disability or treatment began.
• If you do not enroll in Medicare Part B during
your initial enrollment period, your coverage
will be delayed and you will pay a higher
premium for coverage. This will occur unless
you have proof that you were enrolled in
employer or other group health care.
General Enrollment Period
• If you do not enroll in Medicare Part B
during your initial enrollment period, you
have another opportunity to enroll during
the general enrollment period, which runs
from Jan. 1 through March 31 each year. Your
coverage will begin the following July.
• The Social Security Administration assesses a
premium surcharge if you do not enroll when
first eligible. Your Medicare Part B monthly
premium will increase 10 percent for each
12-month period that you were eligible, but did
not enroll in Medicare Part B. You will have to
pay this extra amount for as long as you have
Medicare.
Special Enrollment Period
• The special enrollment period applies if you
are age 65 or older and you have coverage
through an employer (your own or through
your spouse). In this situation, you may delay
enrolling in Medicare Part B without waiting
for a general enrollment period or paying
the 10 percent premium surcharge for late
enrollment.
Special enrollment allows you to enroll during
either of the following timeframes:
• At any time while you have employer group
health coverage (your own or through your
spouse.)
• During the 8-month period that begins with
the month your employer group health
coverage ends or the month employment ends,
whichever comes first. (If you do not enroll
by the end of the eighth month, the general
enrollment guidelines apply.)
Early Medicare Enrollment
Retirees becoming eligible for Medicare before
age 65 must notify OPERS immediately. If they
refuse or fail to enroll in Medicare Parts A and B
when eligible including retroactive effective dates,
the OPERS health care plan will not make up the
difference of what Medicare would have paid if
they had enrolled. In other words, retirees will be
uninsured for a large portion of medical expenses
if they fail to enroll in Medicare Parts A and B once
eligible. OPERS will adjust claims retroactively if
an eligible recipient fails to enroll in Medicare’s
offer of a retroactive effective date.
Medicare Part C and Part D
Medicare Part C and Part D are administered by
private companies and follow provisions and
enrollment guidelines determined by the Centers
for Medicare & Medicaid Services (CMS). The
annual open enrollment period for these plans
begins in the fall.
If your situation is unique or you have any questions about how or when to enroll in Medicare,
contact the Social Security Administration at 1-800-772-1213 or TTY 1-800-325-0778, or visit their
website at www.ssa.gov. Also, the Centers for Medicare & Medicaid Services publishes an official
government handbook, Medicare & You. This publication is available at www.medicare.gov.
5
OPERS and Medicare
OPERS and
Medicare 2015
6
It is important that you and your covered spouse
apply for Medicare through the Social Security
Administration three months (or 90 days)
before you become eligible. OPERS will mail
information to you and your covered spouse
prior to your 65th birthday to notify you of the
Medicare enrollment process. Once you receive
this packet of information, please sign the letter
that will be enclosed with it and return it along
with proof of your Medicare enrollment (a copy
of your Medicare card) to OPERS.
If you or your spouse becomes eligible for
Medicare before reaching age 65 due to a
qualifying Social Security disability or ESRD,
it is your responsibility to inform OPERS
immediately and send proof of your Medicare
enrollment.
All Medicare-eligible participants in the OPERS
health care plan will be automatically enrolled
into the Humana Medicare Advantage Plan
which is a Medicare Part C plan.
(regardless of medical plan administrator) are
also automatically enrolled into the OPERS
Medicare Part D Prescription Plan administered
by Express Scripts.
The Humana Medicare Advantage Plan does
not require participants to use a provider
network and is the only medical coverage
choice for Medicare-eligible participants at
retirement. Medicare-eligible participants
When OPERS receives proof of your Medicare
enrollment, (copy of your Medicare card), we
will initiate your enrollment in the Humana
Medicare Advantage Plan and the OPERS
Medicare Part D Prescription Plan. You will also
receive personalized ID cards from Humana and
Express Scripts.
2015 OPERS Medicare Guide
OPERS and Medicare
OPERS and
Medicare 2015
Medicare Part A — You must have worked 40
credits into the Social Security Administration
(SSA) or paid Medicare tax in order to qualify
for premium-free Medicare Part A. However, you
may be able to receive Medicare Part A through
a spouse’s work record if you do not qualify.
This can include a current, deceased or divorced
spouse in certain circumstances. Please contact
SSA for more detailed information regarding
these qualifications and we recommend that
you sign up for Medicare 90 days before you
turn 65.
If you do not qualify for premium-free Medicare
Part A, you must send proof (a letter from SSA) to
OPERS. Once this letter is received, your OPERS
health care plan will provide substitute coverage
for Medicare Part A.
Medicare Part B — You must enroll in Medicare
Part B when it is first offered. If you do not
sign up, refuse or stop your Medicare Part B
enrollment, we still consider
you to be eligible for
Medicare Part B. You will
be responsible for all
claims (outpatient)
that Medicare would
have paid. OPERS will
not cover these claims
costs and they could be
substantial.
You will still be considered
eligible for Medicare Part B if you do
not enroll because you are covered
by an employer’s plan. OPERS will
estimate what Medicare would have
paid under Part B and will subtract
that amount from total Part B claim
charges before making a payment. If
you or your covered dependents do not
enroll in Medicare Part B when it is first
offered, there will be limitations on your
enrollment in a Medicare-based plan.
Not enrolling in Medicare Part B will increase
your out-of-pocket costs substantially.
Medicare Part C — Currently, all participants in
the OPERS health care plan enrolled in Medicare
Part B will be automatically enrolled into our
group Humana Medicare Advantage Plan which
is a Medicare Part C plan. The Humana Medicare
Advantage Plan is the only medical coverage
choice for Medicare-eligible participants at
retirement.
Medicare Part D — Currently Medicare-eligible
participants in the OPERS health care plan
(regardless of medical plan administrator) will be
automatically enrolled into the OPERS Medicare
Part D Prescription Plan administered by Express
Scripts. The OPERS Medicare Part D Prescription
Plan is geared toward Medicare participants
and requires no additional premium (except for
those with a high income as defined by the Social
Security Administration).
7
OPERS and Medicare
Medicare Supplement Plans— Participants
enrolled in our group Humana Medicare
Advantage Plan do not need to purchase a
Medicare Supplement plan.
Medicare prior to age 65 — Some people
qualify for Medicare due to a qualifying
disability benefit through SSA or due to EndStage Renal Disease (ESRD) (permanent
kidney failure requiring dialysis or a kidney
transplant). Members receiving a disability
benefit effective on or after Jan. 1, 2014, will
have access to health care coverage for the
first five years of their disability based on their
continued eligibility and receipt of a disability
benefit during that time. Health care coverage
for disability recipients will continue past the
first five years only if: 1) the recipient meets
age and service retirement requirements or,
Medicare
Part B Premium
Reimbursement
8
Medicare Part B premium reimbursement will be
reduced incrementally and then eliminated by
2017. The elimination of this reimbursement will
be phased-in with the first reduction occurring in
2015.
• 2015 reimbursement: $63.62
• 2016 reimbursement: $31.81
2015 OPERS Medicare Guide
• 2017 and after: $0
You must be enrolled in the OPERS health care
plan and receiving the Medicare
Part B reimbursement during
2015 to be eligible to receive a
Contact the
reimbursement during 2016.
Social Security
Administration (SSA)
at 1-800-772-1213 with
questions regarding
your Medicare Part B
premium.
2) the recipient enrolled in Medicare, due to a
disability, prior to the end of the five years and
prior to reaching age 65.
In these instances it is your responsibility to
send OPERS proof of Medicare Part A and Part
B coverage immediately. Your Medicare Part B
effective date must be the same date as your
Medicare Part A effective date. Which means
you must enroll in and pay premiums for Part B
back to the date when you were first enrolled in
Part A. If there is a gap between your Medicare
Part A and Medicare Part B effective dates, you
will be responsible for the primary portion
that Medicare would have paid for your Part B
charges during this time period. This amount
could be substantial. It is critical that you pay
the back premiums for Part B coverage.
If OPERS is reimbursing you for your
Medicare Part B premium and you
disenroll or fail to pay our Medicare Part
B premium to the Centers for Medicare
and Medicaid Services (CMS), you will be
responsible to repay OPERS the amount
OPERS overpaid you for your Medicare
Part B reimbursements.
OPERS Medical and Prescription
Drug Plan
Humana Medicare Advantage Plan
OPERS currently offers the group Humana
Medicare Advantage Plan to Medicare-eligible
retirees and their covered, Medicare-eligible
spouses. You and your covered spouse must be
enrolled in Medicare Parts A and B to be eligible
for the Humana Medicare Advantage Plan. OPERS
offers a unique Medicare Advantage plan for those
who do not qualify for premium-free Medicare
Part A. You will not typically find this type of plan
in the individual market. Once you are enrolled
in the group Humana Medicare Advantage Plan,
Medicare services are covered through Humana
and are not paid by Medicare.
All your claims will go directly from your providers
to Humana for processing. Humana will process
claims for any provider that accepts Medicare or
Medicare assignment, regardless of the provider’s
network status. If your provider has any
questions, he or she should call
Humana at 1-877-890-4777.
Medicare coordination with Humana
Medicare has specific rules governing who
(Medicare or Humana) is responsible for paying
the claim. If you are eligible for Medicare and not
covered under another health plan, the group
Humana Medicare Advantage Plan coordinates
payment for Medicare and Humana. In most
cases, if you are eligible for Medicare and
covered under an employer group health plan,
the employer plan is the primary payer and will
pay the claim first. The group Humana Medicare
Advantage Plan will then pay secondary on the
remainder. If you have any questions regarding
how your health care plan coordinates with
Medicare and other health plans, please contact
Medicare or your specific health plan directly.
OPERS does have a unique Medicare
Advantage (MA) plan for those who do
not qualify for premium-free Medicare
Part A. You will not typically find this
type of MA plan in the individual
market. However when you move to the
OPERS Medicare Connector in 2016,
you will have plenty of options.
9
OPERS Medical and Prescription
Drug Plan
2015 Humana Medicare Advantage Plan
Deductible per calendar year
Single
$250* (not included in out-of-pocket maximum)
Out-of-pocket per calendar year
Single
$850* (excluding deductible)
Lifetime Maximum
None
Medical Services
Outpatient Hospice
100%, Covered by Medicare at a
certified hospice agency
Mental Health
96%
Substance Abuse (including Alcohol)
96%
Surgery
96%
Office Visit (Primary Care Physician)
96%
Office Visit (Specialist)
92%
Emergency Services
10
Emergency Room
$50 copay (waived if admitted)
Urgent Care
$50 copay
Preventive**
(must be billed as routine)
Routine Physical Exam
100%
Annual PAP, Mammography, PSA
100%
Colorectal Cancer Screening
(for all participants age 50 and over)
100%
Bone Density Testing
100%
Flu, Pneumonia, Hepatitis B vaccines
100%
Other Medical
2015 OPERS Medicare Guide
Diabetic testing supplies
100%***
Diagnostic lab and X-ray
96%, Lab/pathology 100%, X-ray
Chiropractors
(for manual manipulation of the spine to
the extent covered by Medicare)
96%
Physical Therapy
96%
Ambulance
96%
Home Health Care
100%
Durable Medical Equipment
96%
Inpatient
Inpatient Deductible
None
Semi-Private Room
96%
Pre-Admission Testing
100%
Skilled Nursing Facility
100%
Hospice (Respite Care)
95%, Covered by Medicare at a certified
hospice agency
*Annual out-of-pocket maximum
equals $1100 ($250 deductible
plus $850 out-of-pocket
maximum per year).
**This is just a representative
list of the preventive services
covered. All charges subject to
medical necessity.
***Most diabetic testing supplies
will be covered at 100% under
Medicare Part B.
After a participant meets the
annual deductible and the
out-of-pocket maximum in a
calendar year, all medically
necessary services are covered
at 100%. Plan Features are
general descriptions of coverage.
For details, refer to your Plan
documents or call your Plan
administrator.
OPERS Medical and Prescription
Drug Plan
OPERS Retiree Health Plan, administered by
Medical Mutual
OPERS offers a Retiree Health Plan administered
by Medical Mutual that is for retirees not
yet eligible for Medicare. However, certain
Medicare participants who are not eligible
for coverage in the group Humana Medicare
Advantage Plan will be enrolled in the OPERS
Retiree Health Plan. The following are examples
of exclusions that would result in a Medicare
participant’s enrollment in Medical Mutual:
• Medicare participant is not enrolled in
Medicare B
• Participant is enrolled in another Medicare
Advantage Plan
• Participant is enrolled in primary coverage
through another retiree plan
• Participant is enrolled in an individual
Medicare D plan
• Participant resides outside the United States
If you are eligible for Medicare and enrolled in
Medical Mutual, Medicare (in most cases) will
pay first and the OPERS Retiree Health Plan will
pay after Medicare. You will not be required to
use participating medical providers because
your claims must first be submitted to Medicare
before they are considered for payment under
Medical Mutual.
11
OPERS Medical and Prescription
Drug Plan
OPERS partners with Express Scripts to offer
our Medicare eligible participants the OPERS
Medicare Part D prescription plan, also known
as Express Scripts Medicare™ (PDP).
Retail pharmacy program – Participants can
receive up to a 31-day supply of medication,
plus refills, as prescribed by a physician. Up to a
90-day supply of medication can be obtained at
a retail pharmacy for three times the one month
retail copay. Costs could vary based on your
choice of pharmacy (in or out-of-network).
Mail pharmacy program – Participants can
receive up to a 90-day supply of medication,
plus refills, as prescribed by a physician. To
use the mail pharmacy, participants can place
an order using the Express Scripts website, by
mailing a prescription(s) and the correct copay
to Express Scripts, or by calling 1-800-789-7416.
TTY users should call 1-800-716-3231.
Specialty Medications – Specialty medications
may be purchased through Accredo, Express
Scripts’ specialty mail order pharmacy. These
medications are limited to a 31-day supply. For
more information, please contact Accredo at
1-800-803-2523.
12
2015 OPERS Medicare Guide
OPERS recommends using generic
medications whenever possible. Generic
medications are the most economical
choice for plan participants and OPERS.
Note: Express Scripts will always dispense a generic medication
unless the prescription is marked with “Dispense as Written (DAW)”.
2015 OPERS Medicare Part D Prescription Plan
Deductible
(Calendar year)
$100 annual deductible
for brand medications
Generic
$4 Retail copay
$10 Mail copay
Formulary Brand
30% Retail co-insurance ($20 min/$30 max)
30% Mail co-insurance
($50 min/$75 max)
Non-Formulary Brand
Not covered
Formulary Specialty Drugs
40% co-insurance ($60 max)
(Generic and Brand)
Annual Out-of-Pocket
Maximum
(100% coverage after you have
paid $4,700 in deductible,
copays, co-insurance)
$4,700 per participant
Diabetic medications
$0 copay for generic or
formulary brand
2015 Proton Pump Inhibitor (PPI) Coverage
OTC - examples include:
Prilosec, Omeprazole,
Not covered
Generic - examples
include:
Omeprazole, Pantoprazole
and Lansoprazole
$4 retail
$10 mail
Brand - examples include:
Nexium, Prevacid, Aciphex,
Prilosec, Protonix, Zegerid
and Kapidex
Not covered
“Retail” is a 31-day supply at a retail pharmacy. “Mail” is a
90-day supply via Home Delivery.
Medicare plans are subject to change based on the Centers for
Medicare and Medicaid (CMS) guidelines.
www.Express-Scripts.com
1-800-789-7416 - 24 hours a day,
7 days a week TTY: 1-800-716-3231
OPERS Medicare Connector
In 2016, OPERS will introduce the OPERS
Medicare Connector for retirees enrolled in
Medicare Parts A and B. Participants will select
a Medicare Advantage or Medigap (Medicare
Supplement) plan and a Medicare Part D
prescription plan on the individual Medicare
market that best suits their needs. There are
many very affordable plans available and the
OPERS Medicare Connector will allow OPERS
retirees access to more plan choices than ever
before. Don’t worry - you’re not on your own
making this decision. The OPERS Medicare
Connector offers one-on-one consultations for
retirees enrolled in Medicare Parts A and B.
Not only will retirees be able to choose the right
plan that benefits them and their budget, but
eligible retirees will also be provided with a
monthly Health Reimbursement Account (HRA)
allowance to use toward the premium for their
choice of individual Medicare plan.
The Connector will use OneExchange to provide
retirees with access to plans on the individual
Medicare market. OneExchange is the nation’s
largest and longest-standing private Medicare
exchange.
Although OPERS is moving our Medicare population
to a Connector, we will be an active part of the
transition process. OPERS will stand behind the
work of the OPERS Medicare Connector and we will
be available to retirees should any problems arise
throughout the transition process and beyond.
Three reasons for partnering with a Medicare
Connector
The Medicare Connector provides retirees with affordable choices.
While it may be hard to believe, plans offered
through the individual Medicare market are
more affordable than employer-sponsored, group
Medicare plans including the current OPERS
Medicare plan. The OPERS Humana/Express
Scripts Medicare Advantage Plan costs nearly
$400 per member per month. The total premium
for those who do not qualify for Medicare Part A
is currently $813 per month. However, a 74-yearold retiree (the average age of our retirees) can
buy a Medigap (Medicare Supplement) Plan
F (the Medicare plan with the highest level of
coverage) for less than $200 per month.
1
Individual Medicare plans can offer more
complete coverage.
The most popular individual Medicare plan is
a Plan F Medigap (Medicare Supplement) plan.
Plan F is offered at a lower premium than OPERS
would need to charge for a comparable plan
and provides more complete coverage than the
current OPERS group Medicare plan. Retirees
selecting a Plan F option will have no medical
deductibles or office visit costs.
2
The OPERS group Medicare plan can no
longer compete with the more affordable
plans on the individual Medicare market.
OPERS is committed to being proactive and
offering a quality health care plan for as long as
we are financially able. Due to rising costs, we
knew we would not be able to sustain the health
care program in its current format for more than
10 to 14 years. Change was inevitable. Simply
put, our retiree population is expanding, plan
participants are living longer, and health care
costs continue to rise making it necessary to
change the health care program for current and
future retirees.
3
13
OPERS Medicare Connector
Health Reimbursement Account (HRA)
Allowance
Beginning in January 2016, if you enroll in
an individual Medicare plan using the OPERS
Medicare Connector, you’ll be provided with
a monthly allowance deposited into a Health
Reimbursement Account (HRA).
then seek reimbursement from your HRA. If
you currently have a portion of your health care
premium deducted from your monthly OPERS
pension check, these deductions will cease,
increasing the monthly amount of your pension.
More than 90 percent of current retirees will receive
an HRA allowance of $337 or more a month.
An HRA will be used so that you can receive
your health care premium allowance tax-free.
This requires you to pay your premium first and
The amount of your HRA allowance depends on your years of qualifying service and your age when you
first enroll in the OPERS health care plan. The monthly HRA allowance amount will range between $229
and $405, with more than 90 percent of current retirees receiving $337 or more per month.
Sample monthly HRA activity
My monthly allowance $337
Medigap Plan F (medical) -$191
Medicare Part D Plan (prescription drug) Remaining monthly account balance 14
How can I use my monthly remaining balance?
-$39
$107
1. Apply it to your Medicare Part B premium
2. Apply it to your spouse’s health care premium
3. Apply it to deductibles or other out-of-pocket health care expenses
4. Save it for future health care expenses
For more information on the OPERS Medicare Connector, visit www.opers.org/Connector where you will
find dedicated Connector web pages that include information on what the Connector is, Medicare basics,
enrollment, and the HRA Allowance. The website also features a “Retiree Like Me” section and links to
key resources including the OPERS YouTube channel where you can view several videos describing the
switch to the Connector in great detail. Check the website often for the most current information.
2015 OPERS Medicare Guide
Resources
Frequently
Asked
Questions
F A Q
I’m turning 65, and I can’t afford my Medicare premiums. Where can I get help?
If you qualify, you can receive financial help with Medicare premiums and other costs, like deductibles
and copays. Contact your local Social Security Administration office or state Medical Assistance
(Medicaid) program to find out if you qualify for help. OPERS also has a low income discount program
applicable to some premiums. Please contact OPERS for more information or an application.
I get lots of brochures about Medicare Advantage plans and Medicare supplement policies
in the mail, but I still have questions. Where can I find out more about how these plans and
policies work?
You can get more information about these plans from Medicare through either the Medicare
telephone helpline or the Medicare website. The Medicare website includes an online “Find and
compare plans” tool. The Ohio Department of Insurance at www.insurance.ohio.gov can help you
learn more about these plans, too.
Is there a special enrollment period if I have Medicare due to chronic kidney disease?
Yes, Medicare has specific guidelines if you qualify for Medicare due to End-Stage Renal Disease
(ESRD). You are entitled to Medicare if you will require kidney dialysis or if you will have a kidney
transplant. OPERS will be your primary payor before Medicare during a 30-month coordination period
that has been established by Medicare. After the 30-month coordination period has expired, Medicare
will become your primary payor and OPERS will be secondary. You are encouraged to contact your
dialysis center or your physician for assistance in applying for Medicare through the Social Security
Administration prior to your dialysis start date or kidney transplant.
Will Medicare cover me outside of the United States?
Medicare generally does not cover health care services outside the United States. You must pay for
these services at the time the services are rendered and submit an itemized bill to your OPERS plan
administrator.
How do I pay my monthly Medicare Part B premium through Social Security?
If you will receive a monthly benefit through Social Security, your Medicare Part B premium will likely
be deducted from your Social Security check. If you do not receive a monthly benefit through Social
Security, you may be billed quarterly by Social Security for your Medicare B premiums. In any event, it
is your responsibility to contact Social Security directly to set up your payment options.
What if I worked in a job that didn’t pay into Social Security?
Medicare Part A – You must have worked 40 credits into the Social Security Administration (SSA) or
paid Medicare tax in order to qualify for premium-free Medicare Part A. However, you may be able
to receive Medicare Part A through a spouse’s work record if you do not qualify. This can include a
current, deceased or divorced spouse in certain circumstances. Please contact SSA for more detailed
information regarding these qualifications and we recommend that you sign up for Medicare 90 days
before you turn 65.
Medicare Part B – Any legal U.S. resident age 65 is eligible to purchase Medicare Part B, regardless of
their participation in SSA. Again, we recommend you sign up for Medicare 90 days before you turn 65.
15
Resources
Frequently
Asked
Questions
(continued)
Are retirees required to use a provider network with the Humana Medicare Advantage Plan?
Each time you need health care services, you can choose to receive care from a Humana Medicare
Advantage Plan PPO network provider or you can choose an out-of-network provider who agrees to
accept Medicare or Medicare assignment. Using a network doctor or facility, however, does save OPERS
money which will help keep costs down for retirees. Please consider using a Humana network provider.
What happens to a participant’s coverage with the Humana Medicare Advantage Plan if they
lose Medicare Part B due to non-payment?
Participants must have Medicare Part B in order to be enrolled in the Humana Medicare Advantage Plan.
Humana will work closely with CMS to identify these individuals and they will be handled on a caseby-case basis. These retirees will be responsible for the portion that Medicare would have paid for any
Medicare Part B charges.
Will participants who have early Medicare (disability or ESRD) be covered
under the Humana Medicare Advantage Plan?
Those who have Medicare due to a Social Security Administration disability will be covered under the
Humana Medicare Advantage Plan. Those who have End-Stage Renal Disease (ESRD) and are within
the 30-month coordination period will be covered by Medical Mutual. After the 30-month coordination
period has ended, they will be placed in the Humana Medicare Advantage Plan.
What is a Connector and do other employers utilize them?
A Connector is a company that employs licensed Benefit Advisors who help retirees and spouses select
an individual medical or pharmacy plan, resolve claims issues and change Medicare plans in the future.
They are not affiliated with the “exchanges” as a result of the Affordable Care Act. Connectors have
existed for more than 10 years and many employers have chosen to utilize a Connector model to offer
Medicare plans to their retirees. In fact, a recent study shows that 72% of employers who choose to offer
health care to their retirees will utilize a Connector by 2016.
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How will I pay my premiums when I select a plan through the OPERS Medicare Connector?
2015 OPERS Medicare Guide
Retirees will make premium payments directly to the insurance plan they select. Additionally, retirees
also will need to keep paying their Part B premium. Retirees will then seek reimbursement from their
Health Reimbursement Account (HRA), administered by the Connector, for insurance premiums, Part B
premiums, and additional out-of-of-pocket health care expenses. Using a
Health Reimbursement Account (HRA) allows OPERS to provide an
allowance to retirees without the fund being taxed.
Resources
Important
Reminders
• Apply for Medicare by calling or visiting your
local Social Security Administration (SSA)
office or by contacting SSA at 1-800-7721213 or TTY 1-800-325-0778. Be prepared
to provide your and/or your spouse’s Social
Security number.
• If you qualify for Medicare Part A under any
circumstance, at age 65, or early Medicare due
to a SSA disability or ESRD, you must enroll in
Medicare Part B as soon as you are first eligible
and pay back any Part B premiums due.
Need more information?
Medicare
1-800-MEDICARE
(1-800-633-4227)
www.medicare.gov
Social Security
Administration
1-800-772-1213
www.ssa.gov
Ohio Public Employees
Retirement System
1-800-222-7377
www.opers.org
Ohio Senior Health
Insurance Information
Program (OSHIIP)
1-800-686-1578
www.insurance.ohio.gov
• If you do not qualify for premium-free
Medicare Part A, you still must enroll in and
pay premiums for Medicare Part B as soon as
you are first eligible. You must send OPERS
proof from the SSA that you do not qualify
for premium-free Part A along with proof of
enrollment in Medicare Part B (a copy of your
Medicare card).
• At retirement or prior to age 65, send OPERS
a copy of your Medicare card showing your
enrollment in Part A and Part B or Part B only.
You must also sign the letter that you will
receive from OPERS prior to turning age 65
indicating whether or not you qualify to be
reimbursed by OPERS for your Medicare Part
B premiums. Your spouse is not eligible to be
reimbursed for Medicare Part B premiums.
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Resources
Services and organizations that can answer all your questions about Medicare
Medicare
1-800-MEDICARE
(1-800-633-4227)
www.medicare.gov
Ohio Senior Health
Insurance Information
Program (OSHIIP)
1-800-686-1578
www.insurance.ohio.gov
Ohio Department
of Insurance
Consumer Services
1-800-686-1526
www.insurance.ohio.gov
Medicare Fraud
Reporting
Pro-Seniors
(also legal services)
1-800-488-6070
www.proseniors.org
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U.S. Dept. of Health
& Human Services Office
of Inspector General
1-800-HHS-TIPS
(1-800-447-8477)
www.stopmedicarefraud.gov
Ohio Department
of Aging
1-800-266-4346
www.aging.ohio.gov
Ohio Department
of Job and
Family Services
Ohio Medicaid
1-800-324-8680
www.jfs.ohio.gov/ohp
Ohio Department
of Health
1-800-342-0553
www.odh.ohio.gov
Social Security
Administration
1-800-772-1213
www.ssa.gov
2015 OPERS Medicare Guide