Am I eligible for Medicare?
Generally, you are eligible for Medicare if you have worked for at least 10 years in Medicare-covered employment, are 65 years or older and a citizen or permanent resident of the United States. If you are under age 65, you may qualify for coverage if you have a disability or End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant). To easily determine if you are eligible, simply use the Medicare Eligibility Tool.
If a procedure isn't covered by Medicare, will it be covered by GuideStone?
No, GuideStone Care plans cover only Medicare-approved charges. If a claim is not covered by Medicare, it will not be covered by GuideStone.
How do I know where I am in terms of the "coverage zones"?
You will receive a Prescription Benefit Update from Medco every month you have prescription drug claims. This document helps you keep track of where you are in terms of the coverage zones, with a running total of your individual out-of-pocket as well as your total drug spend to date.
I hear the “donut hole” for Medicare Part D drugs will be eliminated by healthcare reform. When will that happen?
Yes, healthcare reform will gradually eliminate the Part D coverage gap. We offer a more complete description on our Healthcare Reform website. You can read the FAQ or flip through the timeline. On the timeline, scroll to 2012 where you’ll find “Filling the Part D Coverage Gap.”
How can I find out how my drugs are covered on the Senior Care plans?
You can call GuideStone's dedicated line at Medco Health Solutions at 1-866-544-2976 to find out how your drugs are covered under the Care plans. You may ask questions about the formulary, copays and other useful drug information.
Who is counted as an employee?
Definition of an employee: anyone who has been carried on the payroll, whether currently working or not -- include all full-time and part-time employees, any employee receiving disability benefits from which FICA taxes are withheld, and any ministers.
It is important for your employer’s authorized benefits representative to understand who is counted as an employee when completing the Employer Certification – Medicare Secondary Payer Rules form. All employees who are currently active and will receive W-2 forms should be counted. Employees can be full-time or part-time, such as daycare workers, pianists, lawn care workers, etc.
What is an exempt and non-exempt employer?
An exempt employer has 1-19 employees for any 20 combined weeks during the current and preceding calendar years. Medicare is the primary payer of health benefits for their active employees age 65 and older.
A non-exempt employer has 20 or more employees for any 20 combined weeks during the current and preceding calendar years. The weeks are combined and do not have to be concurrent. Medicare pays secondary to an employer-sponsored health plan for employees age 65 and older who are actively working.
What are Medicare Secondary Payer rules (MSP)?
Special regulations determine how a private medical plan, like GuideStone’s plans, pays benefits in coordination with Medicare. These regulations are called Medicare Secondary Payer (MSP) rules and are based on employer size. In general:
- If an employer has fewer than 20 employees over a certain time period, then the employer is considered exempt from MSP rules and Medicare pays benefits before GuideStone’s plans. In this case, Medicare is the ''primary'' payer of claims.
- When Medicare is primary, employees on Medicare may enroll in one of GuideStone’s Care Plans. The Care Plus Plan and the Care Basic Plan both coordinate with Medicare coverage and also provide Part D prescription drug benefits.
- If an employer has 20 or more employees over a certain time period, then the employer is not exempt and Medicare pays after GuideStone plans. In this case, Medicare is the ''secondary'' payer of claims.
- When Medicare is secondary, employees on Medicare stay on GuideStone PPO Medical plans as long as they are actively working at this employer. Because GuideStone PPO benefits are paid before Medicare, the PPO health plans cost more than the Care Plans.
How does Medicare determine payer of benefits?
Special regulations determine how a private medical plan, like GuideStone’s medical plans, pay benefits for actively employed persons or their spouse in coordination with Medicare. These regulations are called Medicare Secondary Payer (MSP) rules and are based on employer size. In general:
- If an employer has fewer than 20 employees on the payroll for any 20 or more calendar weeks in the current or preceding calendar year, then the employer is considered exempt from MSP rules and Medicare pays benefits before GuideStone’s medical plans. In this case, Medicare is the ''primary'' payer of claims.
- If an employer has 20 or more employees on the payroll for any 20 or more calendar weeks in the current or preceding calendar year, then the employer is not exempt and Medicare pays after GuideStone medical plans. In this case, Medicare is the ''secondary'' payer of claims.
How will claims be paid by Medicare and GuideStone?
I am: |
Circumstance |
Pays first |
Pays second |
Working, age 65 or older and: - covered by GuideStone or another employer Group Health Plan, or
|
Employer with less than 20 employees |
Medicare |
GuideStone or other Group Health Plan |
- covered by working spouse's Group Health Plan
|
Employer with 20+ employees |
GuideStone or other Group Health Plan |
Medicare |
Retired, under age 65 and: - covered by GuideStone or another employer-sponsored health plan, or
- covered by working spouse's Group Health Plan
|
Not eligible for Medicare
(under age 65) |
GuideStone or other employer-sponsored health plan or spouse's plan |
No Medicare coverage |
Retired, age 65 or older and: - covered by GuideStone or another employer-sponsored retiree health plan, or
- covered by working spouse's Group Health Plan
|
Entitled to Medicare |
Medicare |
GuideStone or other employer-sponsored retiree health plan or spouse's plan |
Disabled and: - covered by GuideStone or another Group Health Plan, or
|
Employer with less than 100 employees, and not part of a multi-employer plan where any employer has 100+ employee |
Medicare
|
GuideStone or other Group Health Plan |
- covered by working family member
|
Employer with 100+ employees |
GuideStone or other Group Health Plan |
Medicare |
| Diagnosed with End Stage Renal Disease and covered by GuideStone or another Group Health Plan |
First 30 months of Medicare entitlement or eligibility After 30 months |
GuideStone or other Group Health Plan Medicare |
Medicare
GuideStone or other Group Health Plan |
How are claims paid for disabled participants?
Disabled Medicare Participants
The Coordination of Benefits Contractor (“COBC”) for Centers for Medicare and Medicaid Services (CMS) is responsible for determining when Medicare becomes the primary payer of benefits for disabled participants. The current employment status of either the disabled Medicare participant or a member of the participant’s family will determine if Medicare will be primary or secondary under a group health plan.
Since disabled Medicare participants are usually not engaged in active work, CMS has established guidelines for use in determining whether coverage under a group health plan is by virtue of the employee’s or dependent’s “current employment status” for purposes of the primary/secondary payer rules.
Generally, an employee will be considered to have “current employment status” (and Medicare will be secondary payer) if:
- The employee is actively working as an employee, or is the employer (including a self-employed person), or is associated with the employer in a business relationship; or
- The employee is not actively working and is receiving disability payments from the employer that are subject to FICA tax, or would be subject to FICA tax were the employer not exempt from such tax under the Internal Revenue Code (the first six months of disability benefits are subject to FICA tax); or
- If the employee is not actively working but all of the following are true:
- The employee retains employment rights in the industry (e.g., is furloughed, temporarily laid off or on sick leave; is a teacher or seasonal worker who does not work year-round);
- The employee has not had their employment terminated by the employer;
- The employee has not been receiving disability benefits from an employer for more than six months; and
- The employee is not receiving Social Security disability benefits
If an employee does not meet the conditions required to have “current employment status,” then Medicare is primary on the basis of disability.
End Stage Renal Disease (ESRD)
When a participant enrolls in Medicare due to ESRD and is receiving dialysis treatment, Medicare coverage will not begin until the fourth month of treatment. When a participant has group health plan coverage, there is a period of time when their group health plan will pay first on their healthcare bills and Medicare will pay second. This period of time is called a 30-month coordination period. This means if their group health plan doesn’t pay 100% of their healthcare bills during the 30-month coordination period, Medicare may pay for the remaining costs. Medicare is called the secondary payer during this coordination period. The group health plan will pay first on the healthcare bills and Medicare will pay second for a 30-month coordination period.
If you have a disabled employee, please contact your GuideStone Insurance Administrator.
What about Medicare benefits outside the U.S.?
Medicare Primary Participants traveling outside the United States
Medicare benefits are not available outside the United States, except in case of an emergency. GuideStone’s Medicare coordinating plans do not pay benefits for health care services received outside of the United States since these plans cover only those expenses covered by Medicare.
Medicare Primary Participants living outside the United States
If a participant is eligible for Medicare and lives outside of the United States, they should enroll in the PPO Medical Plans. Since benefits cannot be assigned to a foreign provider, the participant will need to pay in full for medical expenses received outside of the United States and file for reimbursement. The participant should obtain a receipt clearly indicating the following information:
- Name of the licensed practitioner
- Diagnosis
- Date of service
- Type of service(s) rendered
- Amount charged for each service
The participant should have the receipt translated into English and the charges converted into U.S. currency values on the date of service. The participant can seek guidance from the nearest American Embassy to find a licensed practitioner or assistance with translating a medical bill.
How do the GuideStone plans coordinate with Medicare?
GuideStone’s medical benefits change when an employee or spouse becomes eligible for Medicare benefits and Medicare is determined to be the primary payer. When Medicare becomes the primary payer for an employee, retiree or spouse, that individual must transfer from their current medical plan to a GuideStone Medicare coordinating plan if they want to continue medical coverage through GuideStone.
- GuideStone’s Medicare coordinating plans coordinate only with original Medicare Parts A and B, not with private Medicare Advantage or other Medicare coordinating plans.
- GuideStone’s Medicare coordinating plans coordinate with Medicare and are designed to cover some of the expenses that Medicare allows but does not pay in full.
- Benefits are paid benefits based on Medicare approved amounts. Services or supplies not covered by Medicare and charges above the Medicare approved amount are not covered under the plans and are the responsibility of the participant.
- All medical expenses covered under Medicare, but not paid in full, can be considered under GuideStone’s plans up to the maximum allowed under the plans.
What is an employer?
An employer may operate as a corporation, partnership, non-profit etc., file tax returns, have employees, withhold taxes on income and need a Federal Tax ID# (EIN). A Federal Tax ID is also known as an Employer Identification Number (EIN). It is a nine-digit number valid in all states for banking, tax filing and other business purposes. For example, if there is a daycare or school as part of a church and each entity has a separate EIN, then each will be considered a separate employer.
What is Medicare Part B?
Part B helps cover medically-necessary services like doctors’ services, outpatient care, home health services and other medical services. Part B also covers some preventive services.
What happens if a participant doesn’t sign up for Medicare Part B and has elected a GuideStone secondary plan that offers Part B benefits?
The group health plan will not pay benefits for Part B charges if the participant is not enrolled in Part B. If Medicare does not pay, GuideStone Financial Resources plan does not pay.
Why is Medicare Part B coverage important?
Part B helps cover medically-necessary services like doctors' services, outpatient care, home health services and other medical services. Part B also covers some preventive services.
What is Medicare Part A?
Part A is Hospital Insurance. Part A helps cover the following:
- Inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)
- Inpatient care in a skilled nursing facility (not custodial or long term care)
- Hospice care services
- Home health care services
- Inpatient care in a religious non-medical healthcare institution
Participants typically don't pay a monthly premium for Part A coverage if they paid Medicare taxes while working. This is called "premium-free Part A."
If a participant is not eligible for premium-free Part A, they may be able to buy Part A if they meet one of these conditions:
- 65 or older, entitled to (or enrolling in) Part B, and meet the citizenship or residency requirements.
- Under 65, disabled and premium-free Part A coverage ended due to returning to work.
In most cases, if a participant chooses to buy Part A, they must also have Part B and pay monthly premiums for both. If they have limited income and resources, their state may help pay for Part A and/or Part B.
What is Medicare Part D?
Medicare-approved prescription benefits are known as Medicare Part D. GuideStone offers Medicare coordinating plans that incorporate the benefits of the Medicare legislation.
GuideStone participants will not need to purchase a Part D plan elsewhere as the prescription benefits included in our Medicare coordinating plans meet or exceed the minimum standard established for Part D coverage.
Note: If a participant chooses to get Part D coverage elsewhere, they will become ineligible for the Medicare coordinating plans that GuideStone currently makes available (except in the instance of qualifying for the low-income subsidy.)
What is the Low Income Subsidy?
The Low Income Subsidy is a feature of the Medicare Part D legislation that will allow those Medicare participants who meet specific eligibility and income criteria to receive prescription drug benefits at a discounted rate or free of charge.
Contact CMS for the current eligibility requirements for the Low Income Subsidy at 1-800-Medicare or www.medicare.gov.
Participants who qualify for this subsidy will be given an opportunity to enroll in a GuideStone Medicare coordinating plan without the prescription benefits included.
Does GuideStone offer coverage for employees/retirees who are age 65?
The Care Basic Plan and Care Today Plan help to minimize out-of-pocket health care expenses by supplementing Medicare coverage. These plans are available to active employees, retirees and dependents who are eligible for GuideStone medical coverage and have Medicare as their primary payer of benefits. Additional senior plans may be available to Group Plans employers.