Medicare

Medicare is a federal health insurance program for individuals:

  • Age 65 or older, or;
  • Individuals under age 65 with certain disabilities, or;
  • Receiving Social Security Administration (SSA) benefits or Railroad Retirement Board (RRB) disability benefits for over 24 months, or;
  • With End Stage Renal Disease (ESRD)

The Medicare program is administered by the Federal Centers for Medicare and Medicaid Services, formerly known as the Health Care Financing Administration (HCFA).

  • Part A (Hospital Insurance) provides coverage for inpatient hospital care, skilled nursing facility care, hospice care and some home healthcare services.
  • Part B (Medical Insurance) provides coverage for outpatient services including physician/professional care, hospital care and other medical services such as labs, x-rays and some medical supplies.
  • Part D provides prescription drug benefits.

Qualifying for Medicare

An individual can qualify for Part A based on his/her own work history or the work history of a current, former or deceased spouse. A person hired by the University on or after April 1, 1986, is subject to withholding of the Federal Medicare tax (1.45% of Medicare eligible salary and an additional 0.9% of salary above a certain threshold), which contributes towards his/her eligibility for premium-free Medicare Part A.

If the Plan Participant:

  • is already receiving retirement benefits from the SSA or the RRB, Medicare will send a Medicare card and automatically enroll the Plan Participant in Parts A and B.
  • is not receiving retirement benefits from the SSA, he/she should contact the local SSA office three months prior to turning age 65 in order to prevent a break in coverage.
  • is not receiving retirement benefits from the RRB, he/she should contact the local RRB office three months prior to turning age 65 in order to prevent a break in coverage.

Age 65 & Over - Medicare Eligibility

Medicare Eligible

Plan Participants must contact their local SSA office upon turning age 65 in order to determine if they are eligible.

  • Part A benefits may be free based on their own or their current, former or deceased spouse's work history.
  • All Plan Participants are eligible for Part B benefits upon turning age 65.

Plan Participants still actively working in a position through the State of Illinois or who have other coverage through a large group health plan may delay enrolling in Part B until they are no longer actively working or retire (whichever is first). Upon this event, a Plan Participant must enroll in Part B in order to avoid a reduction in benefits. Note: It is strongly suggested that an employee register for Medicare through the Social Security Administration office at age 65, even if he/she is continuing to work, in order to avoid this benefit reduction. See Part B Reduction for more information.

If Part B is not purchased at age 65 when the Plan Participant is either retired or no longer actively working, Medicare will impose a 10% penalty for each year without the purchase of Part B coverage.

Medicare Ineligible

If the Plan Participant is ineligible for premium-free Part A, he/she must provide written certification from the Social Security Administration (SSA) that he/she is ineligible based on his/her work history or the work history of any current, former or deceased spouse. The certification must be submitted to your Group Insurance Representative (GIR) upon turning age 65. The Plan Participant is not required to purchase Part B coverage if ineligible for free Part A coverage.

Under Age 65 - Medicare Due to Disability

In order to apply for Medicare disability coverage, a participant must contact the local SSA office or contact the local RRB office. Participants under the age of 65 who are receiving:

  • Social Security disability benefits, will automatically be enrolled in Part A and B coverage when determined to be eligible.
  • Railroad Retirement Board disability benefits, will automatically be enrolled in Part A and B coverage when determined to be eligible.

If a participant is retired or not actively working and is receiving Medicare benefits, the participant must remain enrolled in Part B coverage. If the participant does not enroll or remain enrolled in Part B coverage when Medicare is determined to be primary payer, the State Plan will pay as if the participant has Part B benefits and the benefit reduction applies. See Part B Reduction for more information.

End Stage Renal Disease (ESRD)

Participants of any age may qualify for premium-free Part A on the basis of End Stage Renal Disease (ESRD) if certain criteria are met. In order to apply for Medicare ESRD coverage, a participant must contact the local Social Security Administration Office. Participants who are receiving regular dialysis treatments or who have had a kidney transplant, must make application for Medicare benefits on the basis of ESRD. If it is determined that the participant is eligible for premium-free Part A coverage, the participant must accept the Part A coverage and notify the Central Management Services Medicare COB Unit at 800-442-1300 or 217-782-7007 in order to establish the coordination of benefits.

When Medicare becomes the primary payer, the purchase of Part B is required. If the participant does not enroll or remain enrolled in Part B coverage when Medicare is determined to be the primary payer, the Plan will pay as if the participant has Part B coverage and the Part B benefit reduction applies. See Part B Reduction for more information.

Part B Reduction

Participants who do not enroll in Parts A and B, are responsible for the portion of healthcare costs that Medicare would have covered. Failure to enroll or remain enrolled in Medicare when Medicare is determined to be the primary payer will result in a reduction of eligible benefit payments.

Part D

Part D is part of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, commonly referred to as the MMA.

Qualifications for Part D

Individuals eligible for Part A and/or Part B due to age, disability or End Stage Renal Disease (ESRD) are eligible for the Part D Benefit. It is recommended that University employees do not enroll in a Part D Plan unless qualified for low-income/extra-help assistance because the University coverage is the same or better than the Part D benefit. Please see Notice of Creditable Coverage below.

Notice of Creditable Coverage

The Notice of Creditable Coverage is intended to advise Medicare beneficiaries whether Prescription Drug coverage through the Program is creditable, meaning that coverage is on average, as good as or better than the Part D benefit. You can keep your existing group prescription coverage and choose not to enroll in a Part D plan. This Notice of Creditable Coverage prevents a participant from being penalized if enrolling in Part D at a later date. However, if you drop your coverage through SEGIP and experience a continuous period of 63 days or longer without Creditable Coverage, you may be penalized when enrolling in Part D at a later date.

However, if you drop your coverage through SEGIP and experience a continuous period of 63 days or longer without Creditable Coverage, you may be penalized when enrolling in Part D at a later date.

For Further Information

Visit the Medicare website to:

  • See what Medicare plans are in your area
  • Find doctors who participate in Medicare
  • See what Medicare covers, including preventive services
  • Get Medicare appeal information and forms
  • Get information on the quality of care provided by nursing homes, hospitals, home health agencies, plans and dialysis facilities
  • Find helpful telephone numbers for your area
  • View Medicare publications

With questions about Medicare, call 800-MEDICARE (800-633-4227) or TTY 877-486-2048.

With questions about eligibility for and enrolling in Medicare, Social Security retirement benefits, or disability benefits, call Social Security Administration (SSA) at 800-772-1213 or TTY 800-325-0778.

With questions about eligibility for and enrolling in Medicare through the Railroad Retirement Board, call 877-772-5772 or TTY 312-751-4701.

With questions about the Notice of Creditable Coverage, call CMS Medicare Coordination of Benefits (COB) Unit at 800-442-1300 or 217-782-7007.