Understanding Disability

If you are a State Health Plan member who has been approved for Social Security disability benefits, it is possible you may also be awarded Medicare benefits. Medicare benefits may be awarded retroactively (back-dated) or for a future effective date. It is important to understand that your State Health Plan benefits will change.

Members who have been approved for Medicare benefits are considered Medicare primary and are no longer eligible for enrollment in the 80/20 Plan. Medicare primary members have the following three plan options:

The Humana Group Medicare Advantage Base PPO Plan
The Humana Group Medicare Advantage Enhanced PPO Plan
The Base PPO Plan (70/30) administered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC)

When Medicare is approved due to disability, typically Medicare Part A and Medicare Part B are both awarded. It is important to accept the offer and to arrange to purchase Medicare Part B even if the benefit effective date is retroactive. The details on how to do this will be furnished in the award letter you receive from the federal government.

Please note: Contact the State Health Plan as soon as you have received any Medicare benefits award letter from the federal government at 855-859-0966.

Medicare consists of two parts:

Part A: Pays inpatient hospital bills and skilled nursing facility bills. Members are automatically enrolled and it is normally provided at no charge to those eligible for Medicare.
Part B: Pays outpatient hospital, doctor and other professional bills and requires a monthly payment from the person eligible for Medicare. Member must elect Part B coverage. Please note there is a monthly premium for Medicare Part B which is typically deducted from Social Security benefits.

If you are awarded Medicare benefits retroactively, you will be automatically enrolled into the Base PPO Plan (70/30) as of your Medicare eligibility date. Many members make the mistake of not accepting the offer to retroactively purchase Medicare because their claims were already processed with the State Health Plan paying as primary. It is important to understand how State Health Plan benefits will coordinate with Medicare on the Base PPO Plan (70/30).

The State Health Plan will treat any claims submitted for services as if you are enrolled for coverage under Medicare from the date of eligibility, regardless of whether you have actually enrolled for such coverage.

Once the State Health Plan receives notice of a retroactive effective date under Medicare, claims will be reprocessed all the way back to that effective date under Medicare. This will reduce your claims by the amount that would have been available to you under Medicare, paying the remaining claim amount under the terms of the health benefit plan. As a result, you are responsible for the amount that would have been paid by Medicare Part B even if you do not enroll in Part B.

Although you are considered Medicare primary, you cannot be retroactively enrolled into one of the State Health Plan’s Group Medicare Advantage Plans. This is because of the enrollment notification requirements established for Medicare Advantage plans by the Centers for Medicare and Medicaid Services. You will have the opportunity to enroll in a Medicare Advantage plan for the following benefit plan year during the next Open Enrollment period.

Please note: Medicare Part A and Medicare Part B are required if you wish to elect a Medicare Advantage plan for a future plan year.

If you are awarded Medicare benefits for a future effective date you may be auto-enrolled into one of the State Health Plan’s Group Medicare Advantage Base plans. However, this will be dependent upon when you notify the State Health Plan of the Medicare effective date. Contact the State Health Plan as soon as you have received any Medicare benefits award letter from the federal government at 855-859-0966.

For more information on Medicare and disability, visit their website at www.Medicare.gov.