FEHB and Medicare

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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.”

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About Author

Reg Jones was head of retirement and insurance policy at the Office of Personnel Management. Email your retirement-related questions to fedexperts@federaltimes.com.

2 Comments

  1. I am federal retire over 65. The local doctors office has started charging $51.06 for office visit to receive an allergy injection. This has not been done in the past. Blue Cross paid $20.23 of the office visit charge based on the Medicare Fee Schedule. The doctors office is billing me for the balance of $20.23. Is the doctors office correct in billing me? I have been doing allergy injections for the past 17 years and never been billed for an office visit.

    • Your question falls outside the boundaries of this forum. I suggest you call Medicare and ask them. Here’s the phone number: 1-800-633-4227.

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