Q. I retired from federal service in 2003, am still working and continued my Federal Employees Health Benefits upon retirement. When I turned 65 last September, I and my spouse opted for Medicare Part A only.
On a recent claim approved by the Government Employees Health Association, they sent a cover letter which stated: “Our records indicate that the member is a federal retired employee, and the patient is 65 (my spouse) or older and does not have Medicare Part B. Therefore under the change in Federal Law (5 U.S.C. 8904(B)) we are required to allow no more than the Medicare fee schedule amount for services rendered 1/1/95 and thereafter. The change in Federal Law makes the provider Medicare participation agreement binding.”
The provider did have a Medicare participation agreement, so GEHA reimbursed at the Medicare rate.
If the provider did not have a Medicare participation agreement, would this require GEHA to reimburse at the GEHA rate according to the FEHB contract?
I pay for FEHB/GEHA coverage, so why does a Medicare rate schedule apply when I do not have Part B?
A. If you do not have Medicare Part A, Part B or both, the law requires that your FEHB plan must base its payments on the equivalent Medicare amount set by Medicare’s rules for what Medicare would pay, not on the actual charge. For more information, pull out your plan brochure and look at the section titled, “When you are age 65 or over and do not have Medicare.”