SAMBA and Medicare

If you are age 65 or older, or otherwise entitled to Medicare, SAMBA offers additional protection from the high costs of health care. Whether you are still working or retired, SAMBA and Medicare work together to reduce your out-of-pocket expenses for covered services.

You should advise SAMBA immediately when you enroll in Medicare to ensure that our records are updated correctly.

Coordinating benefits with Medicare has never been easier. For your convenience, when Medicare is your primary insurance carrier we can automatically receive your paid claims from Medicare and process any remaining balances for covered expenses under your SAMBA benefits.

We waive some costs if Medicare Part A and/or Part B is your primary payor. We will waive some out-of-pocket costs as follows:

If you are enrolled in Medicare Part A, we will waive the following:

  • the per confinement copayment for inpatient hospital confinements
  • the coinsurance for inpatient hospital benefits

If you are enrolled in Medicare Part B, we will waive the deductibles, copayments and coinsurances for:

  • Surgery and anesthesia services
  • Mental health and substance abuse benefits
  • Medical services and supplies provided by physicians and other health care professionals
  • Outpatient services by a hospital and other facilities and ambulance services
  • Dental benefits

To see a summary of SAMBA’s health plan benefits when Medicare A & B are primary, please click here.

In cases where we cover a service that is not covered by Medicare, we are the primary payor. In these cases, we do not waive any out-of-pocket costs.

Please refer to Section 9 of the SAMBA Health Benefit Plan brochure, Coordinating benefits with other coverage, for more information about SAMBA and Medicare.

 

Medicare FAQ

What is Medicare?
Medicare is a federal health insurance program for people age 65 years of age or older, some people with disabilities under 65 years of age, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has four parts:

 

  • Part A is hospital insurance that helps pay for inpatient hospital services, home health services, hospice care and inpatient care in a skilled nursing facility. Most people do not have to pay for Part A.
  • Part B is a voluntary medical insurance program that helps pay doctors’ services, outpatient hospital care, emergency room services, durable medical equipment and many other medical services not covered by Part A. Part B has premiums, deductibles and coinsurance you must pay.
  • Part C is a Medicare Advantage Plan. Medicare Advantage Plans are health plan options (like an HMO or PPO) approved by Medicare and offered by private companies available to Medicare beneficiaries. They provide your Medicare health coverage and usually Medicare drug coverage. They aren’t supplemental insurance.
  • Part D is Medicare prescription drug coverage which began January 1, 2006. Medicare prescription drug coverage is voluntary. If you have Original Medicare and you want Medicare drug coverage, you must join a Medicare Prescription Drug Plan.OPM has determined that the SAMBA Health Benefit Plan’s prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. Thus you do not need to enroll in Medicare Part D and pay extra for prescription drug benefit coverage.However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB Plan will coordinate benefits with Medicare.Please refer to your Medicare handbook for a full description of Medicare costs, benefits and other important information.
Do I have to enroll in Medicare when I turn age 65?

No, a member does not have to enroll in Medicare; the decision to enroll in Medicare is yours. If you do not apply for one or more Parts of Medicare, you can still be covered under the FEHB Program. For additional information about enrolling in Medicare, contact the Social Security Administration’s toll-free number (800) 772-1213.

Do my SAMBA benefits change if I enroll in Medicare?

Yes. If Medicare Part B is primary, you will have reduced copays and coinsurance for generic and preferred brand name drugs.

If I enroll in Medicare, would that affect my spouse/dependent’s coverage with SAMBA?
SAMBA benefits for a spouse and/or dependents covered under your family enrollment remain the same when you or another covered family member enrolls in Medicare.
What if I decide not to enroll in Medicare, how will that affect my SAMBA benefits?

If you are age 65 or over and you do not have Medicare, SAMBA must limit our payments for inpatient hospital care and physician care to those payments you would be entitled to if you had Medicare. This is referred to as the Omnibus Budget Reconciliation Act of 1990 (OBRA 90) (hospital care) and the Omnibus Budget Reconciliation Act of 1993 (OBRA 93) (physician care). These Acts mandate the use of Medicare Part B limits for certain services furnished to Federal Employee Health Benefit Program (FEHBP) retirees age 65 and over who do not participate in the Medicare Part A and/or Part B program. For more information, refer to Section 9 of the SAMBA Health Benefit Plan brochure.

How do I determine if Medicare is my primary insurance carrier?
Information on which plan pays primary can be found in the SAMBA Health Benefit Plan brochure and at the OPM website.
Why does SAMBA need my Medicare ID number?
Your Medicare ID number is needed so that your claims can be filed electronically. Your claim will be automatically sent to SAMBA. You and your provider will not need to submit paper claims to SAMBA.
If Medicare is my primary insurance carrier, do I need to file my own claims to receive benefits from SAMBA?
No. Once you notify us that you have enrolled in Medicare and we have determined that Medicare is your primary payor, SAMBA will arrange for your claims to come directly to us after Medicare pays its share.
If Medicare is my primary insurance carrier, do I need to use doctors that participate in SAMBA’s PPO network?

No. However, to ensure that you receive the highest level of benefits, we recommend the use of doctors and hospitals participating in our network whenever possible. This is especially true if services that are eligible for coverage under SAMBA are not covered by Medicare.

If you have Medicare Part A and/or Part B, to get the most from your benefits, it’s best to use doctors who accept Medicare assignment. Your Medicare benefits can be used with any provider accepting Medicare, even if the doctor is not in our PPO network. SAMBA will consider your Medicare deductible or coinsurance for covered expenses after Medicare has processed your benefits as the primary carrier.

What happens if Medicare denies a charge that is covered by SAMBA?
In cases where we cover a service that is not covered by Medicare, we are then the primary payer. In these cases, we do not waive any out-of-pocket costs; normal benefits will apply.
Do I need Medicare Part D for prescription drug coverage when I have prescription drug benefits with SAMBA?

OPM has determined that the prescription drug coverage offered by plans participating in the FEHBP is, on average, comparable to Medicare Part D prescription drug coverage. Therefore, you do not need to enroll in Medicare Part D and pay extra for prescription drug benefits. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage. However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare.

Will I receive a new SAMBA ID card if I enroll in Medicare?
Yes, you will receive one ID card that will serve as both your Medical and Prescription ID card.
Who should I contact about enrolling for Medicare?

To get more information about your Medicare eligibility, how to enroll in Medicare and what Medicare covers, call 1-800-MEDICARE (1-800-633-4227), or visit the Medicare website at www.Medicare.gov.

Who do I contact to learn how my Medicare enrollment affects my SAMBA benefits?

If you have any questions about how your Medicare enrollment will affect your SAMBA benefits, call SAMBA’s Customer Service at (800) 638-6589. You can also find more information about coordinating Medicare with SAMBA benefits in the SAMBA Health Benefit Plan brochure.