The State Health Plan Medicare Supplemental Plan is similar to a Medigap policy — it “fills the gap” or pays the portion of Medicare-approved charges that Medicare does not, such as Medicare’s deductibles and coinsurance. The Medicare Supplemental Plan payment is based on the Medicare-approved amount. Also, because Medicare does not pay for certain services, the Medicare Supplemental Plan will not pay for them either. If your medical provider does not accept Medicare assignment and charges you more than what Medicare allows, you pay the difference.
PEBA automatically enrolls Medicare-eligible retirees and their Medicare-eligible dependents in the State Health Plan Medicare Prescription Drug Program. Most subscribers covered by the Medicare Supplemental Plan or the Standard Plan may be better served if they remain enrolled in this plan. For more information about the Medicare Prescription Drug Program, which is administered by Express Scripts and entitled, Express Scripts Medicare, visit www.Express-Scripts.com or contact Express Scripts’ Medicare Prescription Drug Program Customer Service at 855.612.3128.
When you become eligible for Medicare
If you are a retiree covered by the Standard Plan or the Savings Plan and become eligible for Medicare due to your age, PEBA will send you a letter stating that you will be enrolled automatically in the Medicare Supplemental Plan. If you prefer another health plan, you must inform PEBA by responding to the letter within 31 days of Medicare eligibility.
If you are covered by a PEBA-offered health plan, you may change to the Medicare Supplemental Plan within 31 days of Medicare eligibility. During the yearly October enrollment period, you can change from the Standard Plan to the Medicare Supplemental Plan. Plan changes are effective on January 1 after the enrollment period. If you move out of the United States permanently you may be eligible to change from the Medicare Supplemental Plan to the Standard Plan.
The Medicare Supplemental Plan is available to a retiree and his spouse or children or both who are covered by Medicare Parts A and B. This plan coordinates benefits with the original Medicare plan only. No benefits are provided for coordination with Medicare Advantage plans (Part C). For more information about Medicare, visit www.medicare.gov or call 800.633.4227. If you or your spouse or child is covered by the Medicare Supplemental Plan, the claims of covered family members without Medicare are paid through the Standard Plan’s provisions.
Information about the State Health Plan’s grandfathered status under the Affordable Care Act is located here.