Medicare benefits are secondary to benefits payable under EGHPs for employed individuals
age 65 or over and the spouses age 65 or over of employed individuals of any age.
For items and services furnished from January 1, 1985 - April 30, 1986, Medicare was
secondary payer for employed individuals age 65 - 69 and spouses age 65 - 69 of employed
individuals of any age through 69. For items and services furnished from January 1,
1983, through December 31, 1984, Medicare was secondary payer for employed individuals
and spouses age 65 - 69. Medicare is secondary to EGHP coverage only if the EGHP coverage
is by reason of the employee’s current employment. Health insurance plans for retirees
do not meet this condition.
NOTE: All individuals who are subject to the working aged provision, as well as certain
others, are eligible for the special enrollment period and premium surcharge relief.
(See HI 00805.265ff.)
Medicare beneficiaries are free to reject the employer coverage, in which case they
retain Medicare as the primary coverage. When Medicare is primary payer, employers
cannot offer such employees or their spouses secondary coverage of services covered
by Medicare. However, an employer may offer a supplemental plan that covers items
and services not covered by Medicare such as eyeglasses or routine dental care.
The Age Discrimination in Employment Act (ADEA) which is administered by the Equal
Employment Opportunity Commission requires employers of 20 or more employees to offer
to their age 65 or over employees and to the age 65 or over spouses of employees of
any age, the same coverage, and under the same conditions, as they offer to employees
and employees" spouses under age 65, i.e., coverage that is primary to Medicare. From
January 1, 1985 through April 30, 1986, employers were required to furnish such coverage
to their age 65 - 69 employees and to the age 65 - 69 spouses of employees of any
age through age 69. From January 1, 1983 through December 31, 1984, employers were
required to offer primary EGHP coverage to their employees age 65 - 69 and to their
spouses age 65 - 69.
If you receive any complaints that an employer plan is not in compliance with the
ADEA, i.e., that an EGHP maintains that it is secondary to Medicare, refer the complaint
to the CMS RO, Attention: Associate Regional Administrator, Program Operations. When
complaints are filed, include the individual’s health insurance number, the beneficiary’s
name, the employer’s name and address and the name and address of the EGHP, the individual’s
policy number, and evidence that the EGHP does not have the required coverage.