Medicare Eligibility and your District-Sponsored Medical Coverage
While your retiree health care coverage is available after you become eligible for Medicare, you should understand how Medicare affects health care coverage.
Medicare is the national health care program for individuals who are age 65 and older (and certain other individuals). There are three main parts: Part A, which provides coverage for hospitalization, Part B, which provides coverage for outpatient care, and Part D, which provides prescription drug coverage (All LAUSD plans include prescription drug coverage). To retain your District-sponsored retiree medical coverage after you and/or your spouse/domestic partner become eligible for Medicare for any reason, you must enroll and remain enrolled in Medicare Part A and B. It is recommended that you apply for Medicare 90 days prior to your 65th birthday, contact your local Social Security office for information.
Eligibility for Medicare is considered a major life event therefore you are eligible to change plans within 30 days of the life event.
Lack of Medicare coverage will not affect your dental or vision benefits.
If you like more information, please see the “Medicare & You” guide.
All retirees/spouses/domestic partners must enroll and remain enrolled in Medicare Part A if eligible premium free. If not eligible for Medicare Part A premium free, you must provide ineligibility letters in order to maintain District-sponsored medical benefits.
To be eligible for Part A premium free, an individual must have 40 quarters of Medicare-covered employment. These earnings can be based on his or her own earnings or the earnings of a spouse or former spouse. Contact your local Social Security office for eligibility information.
For retirees who are not eligible for Part A premium free, they may be eligible for the CalSTRS Medicare Premium Payment Plan (MPPP). Contact CalSTRS for eligibility requirements.
If you are not eligible for Medicare Part A premium free or for the MPPP through CalSTRS, to continue your District benefits, you must provide to LAUSD Benefits Administration confirmation letters of ineligibility from BOTH the Center of Medicare and Medicaid Services (CMS) and CalSTRS. By submitting both ineligibility letters, you will only be eligible to enroll in Kaiser Senior Advantage and Anthem Blue Cross EPO. Health Net Seniority Plus and UnitedHealthcare® Group Medicare Advantage HMO (formerly known as Secure Horizons) require eligibility and enrollment of Medicare Part A and B.
For Spouses/Domestic partners who are not eligible for Medicare Part A premium free, they must submit to LAUSD Benefits Administration a confirmation letter of ineligibility from CMS only.
All retirees/spouses/domestic partners must enroll and remain enrolled in Medicare Part B and remit the applicable premium to CMS in order to maintain District-sponsored medical benefits. If you stop paying for your Medicare Part B premium at any time for yourself and/or your spouse/domestic partner, your District sponsored medical benefits will terminate. For Medicare Part B premiums, contact your local Social Security office.
The Medicare Prescription Drug Plan (PDP), also known as Medicare Part D, became available January 1, 2006. Although you have the option of enrolling in a Medicare PDP, in most cases these plans will not provide you with any additional advantages. The LAUSD prescription drug plan is at least as good as the standard Medicare Part D benefit for most Medicare eligible participants LAUSD will continue to provide your current prescription drug coverage through Kaiser Senior Advantage, UnitedHealthcare® Group Medicare Advantage HMO, Health Net Seniority Plus or CVS Caremark the prescription drug provider for Anthem Blue Cross EPO plans. If you elect to enroll in a PDP outside your current plan, the District will cancel your medical and prescription coverage.
Effective January 1, 2011, higher income Medicare beneficiaries who are enrolled in Medicare Advantage Plan (Kaiser Senior Advantage, Health Net Seniority Plus and UnitedHealthcare® Group Medicare Advantage HMO (formerly known as Secure Horizons) will be subject to a Medicare Part D premium if their gross adjusted income exceeds the threshold amounts listed below:
Medicare Part D monthly adjustment amounts:
|
Monthly Part D Premium Adjustment*
|
Individual’s Annual Income |
Married Couples Filing Jointly Annual Income |
Married Couples Filing Separately Annual Income |
|
$0 |
$85,000 or less |
$170,000 or less |
$85,000 or less |
|
$12 |
$85,001 - $107,000 |
$170,001 - $214,000 |
n/a |
|
$31.10 |
$107,001 - $160,000 |
$214,001 - $320,000 |
n/a |
|
$50.10 |
$160,001 - $214,000 |
$320,001 - $428,000 |
$85,001 - $129,000 |
|
$69.10 |
Above $214,000 |
Above $428,000 |
Above $129,000 |
*Premiums are subject to change.
The Part D premium will not be paid by the District or your medical plan; you are required to remit the specified payment to Medicare to maintain your District provided coverage.
There are three (3) timeframes in which eligible individuals can enroll in Medicare:
1. Initial Enrollment Period. This is when individuals who become eligible can enroll in
Medicare: three months prior to their 65th birthday, during the month of their 65th birthday, or within three months after their 65th birthday;
2. Special Enrollment Period. This is when those who are 65 and older who were previously covered as an active employee under their employer’s plan or under their working spouse’s plan and are no longer covered. These individuals are eligible to enroll in Medicare as soon as they lose this coverage (e.g., they retire or their spouse/domestic partner retires);
3. General Enrollment Period. This Open Enrollment period is from January through March for coverage effective July 1 of the same year (coverage would start on July 1).
To enroll in Medicare and maintain your District-sponsored medical benefits: contact the nearest Social Security office three months before the first of the month in which you (or your eligible dependent) reach age 65. For more information you may contact Medicare directly at (800) 633-4227 (800-MEDICARE) or at (877) 486-2048 (TTY) for the hearing impaired. You may also visit the Medicare website at http://www.medicare.gov or the Social Security website at http://www.socialsecurity.gov or (800) 772-1213.
Retirees and/or their spouse/domestic partner age 75 and older as of January 1, 2010 (Retirees born prior to January 1, 1935), were grandfathered-in at their current Medicare Part A and B enrollment levels.
For all other retirees, in order to continue your District-sponsored benefits: Mail or fax a photocopy of your Medicare card or letter from CMS which provide proof of eligibility for Medicare Part A and B, in the month prior to your 65th birthday. If you are only eligible for Medicare Part B, provide the ineligibility letters for Medicare Part A described above. Please include retiree’s name, employee ID or Social Security number to LAUSD Benefits Administration at P.O. Box 513307, Los Angeles, CA 90051-1307 or via fax at 213-241-4247.
As a Medicare eligible retiree, you have to enroll in the Medicare Advantage plan. Medicare Advantage plans include Kaiser Senior Advantage, Health Net Seniority Plus and UnitedHealthcare® Group Medicare Advantage HMO (formerly known as Secure Horizons). With these Medicare Advantage plans, you will be responsible for paying a small copayment for most outpatient services, and the plan generally pays 100% of hospitalization. For services that are covered by Medicare, the plans will file a claim with Medicare on your behalf, and will coordinate benefit payments directly with Medicare. Some providers and services may vary with Medicare Advantage plans, please contact your plan for details.
Once you have completed the enrollment process for Medicare, there are additional requirements by some providers:
- For Kaiser HMO, you must complete and submit a Kaiser Advantage group enrollment form in the month prior to your 65th birthday. You will then be enrolled in Kaiser Senior Advantage once the form is received and approved by Kaiser.
- For Health Net HMO, you must complete and submit a Health Net Seniority Plus group enrollment form in the month prior to your 65th birthday. You will be enrolled in Health Net Seniority Plus once the form is received and approved by Health Net. The Health Net Seniority Plus network is different than the Health Net HMO network. Please contact Health Net for provider information.
- If you wish to enroll in UnitedHealthcare® Group Medicare Advantage HMO (formerly known as SecureHorizons), you must notify the District and submit a UnitedHealthcare® group enrollment form to United Healthcare in the month prior to your 65th birthday. You will be enrolled in UnitedHealthcare® Group Medicare Advantage HMO once the form is received and approved by UnitedHealthcare® Group Medicare Advantage HMO. Retiree and spouse/domestic partner must both be over 65 and eligible for Medicare Parts A and B to qualify for this plan
When you turn 65, Anthem Blue Cross HMO plan will change to Anthem Blue Cross EPO plan. For Anthem Blue Cross EPO plan, there is no Medicare enrollment form. Once you are enrolled in Medicare Parts A and B as required, Medicare becomes your primary coverage and the Anthem Blue Cross EPO plan will pay your coverage as secondary. This means you or your provider must submit a claim to Medicare and Anthem Blue Cross EPO. Anthem Blue Cross EPO for Medicare eligible retirees and dependents will provide full integration with Medicare for allowable expenses and covered services. The plan requires that you must use an Anthem Blue Cross provider who is also a Medicare provider for covered services to receive any benefits from the plan. Anthem Blue Cross and Medicare will not pay for any services from a non-Medicare provider. After a retiree or their dependent satisfies the $300 deductible, Anthem Blue Cross will pay the difference between what Medicare pays, and cost of services up to 100% of allowable Medicare charges (but not more than the amount at 80% if Medicare were not present). Retirees/dependents that are not eligible for Medicare Part A may be responsible for additional costs.
