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Medicare

Welcome to the School District of Philadelphia's "Medicare" page!

Please click on the links below for more information on how this program works:

General Information

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, retirees, the disabled, and children of deceased workers and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).  

This program is funded by FICA (Federal Insurance Contributions Act) taxes on payroll on both employees and employers.  The maximum amount of earnings subject to the Social Security tax for 2013 is $113,700.

Here are the ABC's and D of Medicare

Medicare Part A (Hospital Insurance): Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.

Medicare Part C Sometime called "MA Plans," are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, you still have Medicare. You get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan and not Original Medicare.

Medicare Part D (prescription drug coverage): Part D adds prescription drug coverage.  These plans are offered by insurance companies and other private companies approved by Medicare.  Unions may also sponsor Retiree Drug Subsidy Plan (RDS) that provide Creditable Coverage".  These plans are an alternative to Medicare Part D for eligible retirees.

For more information, see Medicare's website, medicare.gov

Most active employees who are covered by medical insurance through their employment are not required to enroll in Medicare; nor are their covered dependents.  Most employees forgo enrollment in Medicare Parts B & D until they retire.  Check with Social Security for details regarding your ability to delay enrollment in Parts B & D without penalty. Employees who enroll in Part B while still working are usually not subject to late enrollment penalties as long as they have maintained continuous medical coverage through from age 65 on. If you decide to forgo Part B when you are first eligible, confirm your ability to avoid late enrollment penalties with Social Security. Employees and their legal spouses are usually allowed to enroll in Part B at any time while continuously covered by medical insurance through active employment (or, immediately upon termination of employment or retirement).

If you retire and you or your spouse  are 65 or older or eligible for Medicare due to a disability, in almost all cases, you should enroll in both Medicare Parts A and B to have full coverage of doctors' services and other medical care.  COBRA and Retiree coverage may look the same as the coverage you had when you were currently working, but it works differently. This coverage is secondary to Medicare, which means that it typically pays after Medicare pays. In order to be fully covered, for Medicare-covered services you usually need both Part A and Part B.

If you postpone enrollment in Medicare, you may have to pay a penalty for late enrollment in addition to the monthly premium. Additionally, if you delay enrollment in Part B, you may also have gaps in your coverage, because you will have to wait until the General Enrollment Period to enroll in Part B. The General Enrollment Period is January 1 through March 31 each year, with coverage beginning July 1.

Other Important Information:

When retirees become eligible for Medicare, by age or disability, if they are collecting a pension, they have a qualifying event that enables them to enroll in Health Options Program (HOP) Medicare plans.  HOP operates for the sole benefit of participants of the Pennsylvania Public School Employees' Retirement System (PSERS).   If you are eligible for Premium Assistance and choose HOP-sponsored medical coverage, PSERS will pay up to $100 per month for your HOP monthly premium.

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Who's eligible for this benefit?

All employees are subject to FICA (Federal Insurance Contributions Act) taxes on payroll.

Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years or older and a citizen or permanent resident of the United States.  

 

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How and when can I enroll for these programs?

Employees are automatically enrolled in the FICA (Federal Insurance Contributions Act) payroll tax. 

Social Security manages enrollment in Medicare Parts A and B.   You can file for Medicare online when you file for retirement.  If you do not wish to start receiving social security benefits, you can make an appointment with Social Security by calling 1-800-772-1213 (TTY 1-800-325-0778) 7 a.m. and 7 p.m., Monday through Friday.   If you are already receiving Social Security benefits, you will automatically be enrolled in Medicare Parts A and B.  However, because you must pay a premium for Part B coverage, you have the option of turning it down.  You will be contacted by mail a few months before you become eligible and given all the information you need.

Check Medicare's website to find out when you are eligible and when you should enroll in Medicare parts A and B.  

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When and how can I make changes or unenroll?

Check Medicare's website to find out when you are eligible and when you should enroll in Medicare parts A and B.  

Since it's becoming more common for individuals to not collect Social Security benefits prior to turning 65, as they continue to work and have employer group health plan coverage, Medicare provides a handy tip sheet to explain when you can enroll     

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What does the deduction look like on my paycheck?

There will be several items on your stub related to FICA. 

YTD FICA Med Earnings: Year-to-date earnings that have been subject to FICA Medicare withholding.

FICA Med Earnings: Amount of this paycheck's earnings that are subject to FICA Medicare withholding.

FICA Med: Mandatory Deduction for the Medicare portion of FICA.

 

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How do I use this benefit throughout the year?

As an active employee in the SDP Group coverage, unless you have End-Stage Renal Disease (ESRD), the School Districts coverage is primary, and Medicare is secondary, meaning you will use only your employee coverage.  If you have ESRD, undergo dialysis or had a kidney transplant, contact Employee Benefits to discuss how this may affect your coverage.

Once your coverage is no longer based on your active employment, Medicare becomes primary over any retiree or COBRA coverage.  If you have not elected and enrolled in Medicare coverage through HOP or another source, Medicare will be primary, meaning you must show both you Medicare card and medical insurance card when you receive services.  How claims are processed and adjudicated following Medicare rules and guidelines. 

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What Medicare coverage does the SDP Offer?

Currently working employees and their dependents enrolled in the School Districts medical coverage do not need to enroll in a Med-i-Gap, Medicare Supplement or Medicare Advantage (Part C) plan. 

Retirees needing Medicare coverage should contact Health Options Plan (HOP), the Health insurance group for the Public School Employees' Retirement System (PSERS) regarding coverage options.

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Forms

CMS-L564 Request for Employment Information.  The purpose of this form is to provide documentation to Social Security that you have been continuously coverage by a group health plan based on current employment, with no more than eight consecutive months of lapses in coverage.

 

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Frequently Asked Questions

What is Initial Enrollment Period (IEP)?  The 7‑month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

What is a Special Enrollment Period?  You can typically delay enrollment in Part B without penalty if you were covered by employer health insurance through your or your spouse's current job when you first become eligible for Medicare. You can enroll in Medicare without penalty at any time while you have group health coverage and for eight months after you lose your group health coverage or you (or your spouse) stop working, whichever comes first.

When can I enroll in Medicare if I missed my initial enrollment period?  If you have employer insurance through a current job or your spouse's job at the time you became eligible for Medicare you may be eligible for a Special Enrollment Period, which means you can enroll in Medicare without penalty at any time while you have group health coverage and for eight months after you lose your group health coverage or you (or your spouse) stop working, whichever comes first.

 

What is ESRD? End-Stage Renal Disease (ESRD) is permanent kidney failure requiring dialysis or a transplant.

What is FICA? FICA is an abbreviation for the payroll taxes for Social Security and Medicare that were enacted as part of the Federal Insurance Contributions Act.

What is Medicare Part A? Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

 

What is Medicare Part B?  Medicare Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.

 

What is Medicare Part C?  Medicare Part C also called "MA Plans," are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, you still have Medicare . You'll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan and not Original Medicare.

 

What is Medicare Part D (prescription drug coverage)? Medicare Part D is insurance for prescription drugs.  These plans are offered by insurance companies and other private companies approved by Medicare.

 

What is a Retiree Drug Subsidy Plan (RDS)?  Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) contains a provision governing the special retiree drug subsidies to encourage unions to continue providing high quality prescription drug coverage to their retirees. This program enable unions to obtain the Medicare subsidy without disrupting their current coverage.

What is Creditable Coverage?  This term means that benefits provided a drug plans are at least as good as those provided by the Medicare Part D program. This may be important to people eligible for Medicare Part D but who do not sign up at their first opportunity because if the other plans provide creditable coverage, plan members can later convert to Medicare Part D without paying higher premiums than those in effect during their open enrollment period.

 

Where can I get help?  Resources include:

CARIE (Center for Advocacy for the Rights and Interests of the Elderly) at 215-545-5728 or Outside Philadelphia at 1-800-356-3606

Apprise health insurance counseling 1-800-783-7067

     Bucks County 215-348-0510
     Chester County 610-344-5004
     Delaware County 610-237-6222
     Montgomery County 610-278-3601
     Philadelphia County 215-456-7600

     Burlington County 609-265-5069
     Camden County 1-877-222-3737
     Gloucester County 856-384-6900

Pennsylvania Department on Aging  "Enhancing the quality of life of all older Pennsylvanians by empowering diverse communities, the family and the individual."

 

 

 

 

 

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