How Do Medicare And FEHB Work Together?

• The federal employee health benefits (FEHB) program provides health insurance for federal government employees or retirees and their families. 

• Medicare is a government healthcare program for those 65 and older, younger Americans with disabilities, or those with end-stage renal disease (ESRD).

• Medicare coverage can be combined with FEHB coverage. FEHB will be the beneficiary’s primary coverage until retirement. 

FEHB plans are part of a healthcare program created for federal employees to provide health insurance for workers and their family members. Plans available through the FEHB program include: 

• Fee-for-service plans

• Health Maintenance Organizations (HMOs)

• Point of Service (POS) product plans

Note: FEHB provides a vast array of healthcare plans to choose from. Compare plans at this resource.

Medicare is a government health benefits program that provides health insurance for those 65 and older, younger Americans with disabilities, or those with end-stage renal disease (ESRD). There are various types of Medicare available for enrollment. 

Some Medicare benefits programs are: 

• Original Medicare plans

• Medicare Advantage (MA) plans (Medicare Part C)

• Medicaid-Medicare (Dual-Enrollment Program) plans

• Medicare supplement plans (Medigap)

There are various parts to Medicare, each one responsible for coverage for specific health care services. 

Medicare Part A is Medicare’s hospital insurance. Medicare Part A provides coverage for the following services: 

• Inpatient hospital care

• Skilled nursing facility care

• Nursing home care (non-custodial or long-term care)

• Hospice care

• Home health care

Enrollment for Medicare Part A coverage is usually automatic.

Medicare Part B is Medicare’s medical insurance. If you choose to enroll in Part B, coverage consists of two main types of covered services:

• Medically-necessary care

• Preventative services (i.e. vaccinations)

Medicare Advantage Plans (Medicare Part C)

Medicare Part C is Medicare Advantage plans, also known as MA plans. Part C is provided through private insurance companies. Essentially, Medicare Advantage plans are enhanced versions of Original Medicare, meaning these types of health plans provide both Medicare Part A and Part B, in addition to other benefits, sometimes prescription drugs. 

Note: Learn more about what Medicare Part C is at this resource.

Medicare Part D 

Medicare Part D is Medicare prescription drug coverage. Enrollment for Medicare Part D is not automatic. Medicare beneficiaries must either enroll in a separate Medicare drug plan or find a Medicare Advantage plan that includes drug coverage. Do note that not all MA plans provide coverage for prescription medications. 

Medicare and FEHB can be coordinated. Knowing when each plan is the primary payer or the secondary payer will be vital to understanding how this coordination functions. Learn when each one is which at this resource.

Active or retired federal employees currently enrolled, or eligible, for Medicare can coordinate Medicare coverage with their FEHB coverage. In fact, at times it is recommended to do so because having both health insurances can provide federal or active government employees with more comprehensive healthcare coverage. Of course, individual circumstances in both health and finances will ultimately be the determining factor in if it makes sense to do so.

While FEHB plans generally cover the same services as those within Medicare, FEHB does provide coverage for services Medicare does not, and vice versa. For example, FEHB covers emergency care outside of the U.S., and Medicare does not. As well, some FEHB plans also cover dental and vision services. Medicare does cover some orthopedic and prosthetic services, durable medical equipment, home health care, limited chiropractic services, and certain medical supplies, which some FEHB plans may only partially cover (or not at all). 

FEHB and Prescription Drugs

All FEHB plans provide prescription drug coverage. As such, Original Medicare beneficiaries who choose to combine health care with FEHB do not need to enroll in Medicare Part D because they will already have prescription drug benefits. 

However, if an enrollee does combine FEHB and Medicare Part D, Medicare acts as the primary payer with FEHB acting as the secondary. This means that Medicare receives claims first and FEHB will review and cover claims of the prescription drug costs that were not covered by Medicare.

All FEHB plans provide prescription drug coverage. As such, Original Medicare beneficiaries who choose to combine health care with FEHB do not need to enroll in Medicare Part D. 

That said, if a Medicare beneficiary loses or unenrolls in FEHB coverage, they will have to pay a higher premium for Medicare part D if they go without equivalent prescription drug coverage for a period of 63 days or longer. Learn more at this Office of Personnel Management resource.

What Else to Know:

• FEHB plan brochures explain exactly what services and supplies are covered, as well as the level of coverage. Each brochure is formatted in the same way, so these are easy to read. Review 2022 FEHB plan brochures here.