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:
If you are enrolled in Medicare Part B, we will waive the deductibles, copayments and coinsurances for:
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.
The Plan also offers an Enhanced Benefit Opportunity through the UnitedHealthcare Medicare Advantage (PPO) for the SAMBA Health Benefit Plan. Voluntary enrollment in the Medicare Advantage Plan will be limited to those annuitants who have Medicare Part A and Part B primary coverage. Click here for more information.
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:
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.
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.
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.
Information on which plan pays primary can be found in the SAMBA Health Benefit Plan brochure and at the OPM website.
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.
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.
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.
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.
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.
Yes, you will receive one ID card that will serve as both your Medical and Prescription ID card.
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.
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.
