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State of Delaware Office of Pensions

Medicare FAQ's

These are Frequently Asked Questions regarding: Medicare, Medicare Supplement & Express Scripts Medicare (Qualified Part D) Prescription Drug Plan (PDP)


Please click on the question below to expand and see the answer.

Medicare is our country’s federal health insurance program for people age 65 or older. People younger than age 65 with certain disabilities, permanent kidney failure (End Stage Renal Disease), or amyotrophic lateral sclerosis (Lou Gehrig’s disease) can also qualify for Medicare. The program helps with the cost of health care, but it does not cover all medical expenses or the cost of most long-term care.

Note:
If you, your spouse, or dependent become eligible for Medicare due to disability and are enrolled in benefits through the Pension Group, it is very important that you notify the Office of Pensions at 800-722-7300 for information regarding enrollment requirements.
In accordance with the Group Health Insurance Plan (GHIP) Eligibility and Enrollment Rules 4.09 and 4.12, if you are enrolled through the State Pension Group as a retiree, Long-Term Disability Beneficiary, spouse or dependent, you must enroll in Medicare Part A (Hospital) and Part B (Medical) “Original Medicare”, insurance when eligible due to either turning age 65 or receiving Social Security Disability benefits for a period of 24 months. Employees receiving Long-Term Disability (LTD) and enrolled in insurance through the GHIP must enroll in Medicare Parts A and B upon becoming eligible. You can delay Part B enrollment only if you will qualify for a special enrollment period with the Social Security Administration (SSA) – See Question 3. Visit ssa.gov for additional information.
  • If you or your spouse/dependents are enrolled in health insurance through an active employer group (not a retiree group), you can delay Medicare Part B enrollment until the active employer group coverage ends. When the employer group coverage ends, then you must contact the SSA and enroll in Medicare Part B based on SSA rules for a Special Enrollment Period (SEP). When enrolled in healthcare insurance through the State of Delaware (SOD) Pension Group once you become eligible for Medicare insurance, SOD coverage can no longer continue as the primary insurer.

  • Active employer group coverage is offered through current employment not retirement. The health insurance plan through the SOD Pension Group is not considered active employer group coverage and cannot be used to obtain a Medicare Special Enrollment Period through the SSA. If you will be delaying Part B enrollment, contact our office to coordinate your coverage. The insurance through you or your spouse’s current employer must be the primary insurance coverage in order to delay Medicare Part B enrollment.
When your employer group coverage is ending, you need to apply through the SSA for Medicare Part B insurance three months prior to the coverage termination. To apply for Part B as a Special Enrollment Period (in order to avoid a premium penalty), your employer needs to complete a CMS L-564 verifying dates of coverage under the active employer group and to verify the date insurance will be terminated through the active employer group. The CMS L-564 Form needs to be submitted to the SSA along with a CMS 40B Application for Enrollment in Medicare Part B insurance requesting the Part B effective date. In order to enroll in the Medicare Supplemental Plan offered by SOD Pension Group, you need to notify the Office of Pensions by submitting a copy of your Medicare Part B enrollment verification along with a Medicare supplement plan application.

Additional information can be found on medicare.gov.
If you are currently collecting Social Security retirement or disability benefits, your Medicare Parts A and B should be automatically enrolled, and you should receive a Medicare card by mail. If you are not collecting Social Security benefits, you must contact the SSA to enroll in Medicare Part A and Part B.

  • You should apply for Medicare through the SSA three months prior to the month you turn age 65.
  • You can enroll online at ssa.gov or contact SSA at 1-800-772-1213. Visit medicare.gov for additional information.
  • SSA may question if you are enrolled in health insurance coverage through a group health plan. Coverage with a group health plan is provided through current employment, either yours or the employment of a spouse. According to Social Security, COBRA and retiree health coverage do not count as current employer coverage.
In order to meet the enrollment deadline for the Special Medicfill Plan, the Office of Pensions must receive a copy of your Medicare card at least 30 days prior to your Medicare eligibility start date (either due to obtaining the age or 65 or after 24 months of becoming approved for Social Security Disability benefits).
If you have not received a Medicare card, please contact SSA at 1-800-772-1213 to check your enrollment status. It is highly recommended that you create an online account through ssa.gov and print an enrollment verification letter. This letter can be forwarded to the Office of Pensions as verification of your enrollment to expedite your supplement and prescription insurance enrollment. The benefit verification letter must verify your unique Medicare Beneficiary ID (MBI) number and enrollment effective dates of both Medicare Part A and Part B insurance.

Note
The Office of Pensions does not have direct access to Social Security or Medicare records. The Pension Office must receive documentation, either the SSA benefit verification letter or a copy of your updated Medicare card, in order to enroll you in the Special Medicfill Plan. A copy of your Medicare card is required for your pension file. It is important that you include your Pension Employee ID or Social Security number on the documentation to expedite your enrollment.
You are eligible for premium-free Part A if you are age 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. Please contact the Office of Pensions if you do not qualify for free Part A insurance.

There is a monthly premium cost for Part B (medical) insurance. In order to remain enrolled under the SOD Pension Group insurance, you are responsible to maintain Part B enrollment and pay Part B monthly premiums to the SSA. The Office of Pensions is not responsible for your Part B enrollment and/or payment of your monthly Part B premiums. Failure to maintain Medicare Part A and B enrollment with the SSA will result in termination of medical and prescription drug coverage through the SOD Pension Group.

  • The monthly cost and payment arrangement for Part B monthly premiums is determined by and paid directly to the SSA. Part B premiums are not deducted from your pension payment. If the SSA determines that you are a high-income earner, a higher Part B premium and an additional premium for enrollment in a qualified Part D prescription plan is charged. This is an Income-Related Monthly Adjustment Amount (IRMAA). You are responsible to pay all required premiums directly to the SSA. Failure to pay premiums will result in the termination of Medicare insurance.
If the medical provider accepts Medicare and the service(s) are covered by Medicare, Medicare will typically pay 80% of the allowable charges of the claim. The Official U.S. Government Site for Medicare (medicare.gov) is user friendly and provides a wealth of information on this topic. You may also contact Medicare by telephone at 1-800-MEDICARE (1-800-633-4227).
The State of Delaware provides a Medicare Supplement Plan called Special Medicfill. This is a Medigap plan administered by Highmark of Delaware. The Special Medicfill plan is offered with or without qualified Part D prescription drug coverage that is administered through Express Scripts Medicare.
Once Medicare becomes your primary insurance, Medicare Supplement plans will only cover if Medicare pays as the primary payer. Special Medicfill typically covers 20% of allowable charges of the claim balance after Medicare pays as primary. This plan also covers the Medicare Part B deductible. Please present both your Medicare and Highmark Medicare Supplemental cards when using medical/hospital services.

For more information on the Highmark Medicare Supplement plan, Special Medicfill, please visit: https://dhr.delaware.gov/benefits/medicare/highmark.shtml.
This is an enhanced Medicare Part D prescription plan. The plan does not have a deductible and has a wrap in place during the coverage gap (“donut hole”) period: Copays will not increase during the coverage gap period.

Prescription Coverage 30-Day Supply 90-Day Supply
Tier 1 Generic $8.00 $16.00
Tier 2 Preferred (Formulary) $28.00 $56.00
Tier 3 Non-Preferred Brand/Generic Drugs $50.00 $100.00

For more information, please visit: https://dhr.delaware.gov/benefits/prescription/medicare/.
The premium is based on retirement date and your years of creditable service earned while working for the State of Delaware. Please refer to the Office of Pensions website at Rate Tables for Medicare Pensioners for rate details. Contact the Benefits Section of the Office of Pensions if you have questions.
Special Medicfill monthly premium cost or plan changes, including prescription co-pays, are communicated each year at the end of September. Open enrollment for the Special Medicfill Plan is held annually in the month of October and any elected changes are effective the following January 1st.
Vision and dental insurance plans are separate plans from your medical coverage. Enrollment in Medicare will not affect your enrollment in these plans. If you wish to make changes to these plans, you must do so during the open enrollment period held annually in May or within 30 days of a qualifying event (enrollment in Medicare is not a qualifying event).
Once a copy of your Medicare card is received, you will be enrolled in the Special Medicfill Plan with prescription coverage. Your spouse and any dependents currently enrolled in coverage will continue to be enrolled in their current elected plan under a separate contract. You will receive new cards for all members enrolled in coverage from the carrier(s).

Your medical deduction will change to reflect the plan adjustments. You will be charged the current monthly rate for Special Medicfill and the current monthly rate for the plan(s) in which your non-Medicare family member(s) remain enrolled.
The Centers for Medicare & Medicaid Services (CMS) only allows for enrollment in one qualified Part D prescription drug plan. Enrollment in another Part D plan will terminate prescription coverage with the SOD Express Scripts prescription drug plan.
  • The SOD offers enrollment in the Special Medicfill Plan with OR without the qualified Part D prescription drug coverage. When you submit a copy of your Medicare card, you are automatically enrolled in Special Medicfill with the qualified Part D prescription plan. Please contact the Office of Pensions for assistance if you are enrolled in another qualified Part D plan and to enroll in the Special Medicfill Plan without prescription drug coverage.
Enrollment in a Medicare Advantage plan is not compatible with the Special Medicfill Plan. Medicare does not allow for coordination of benefits between the two plans. The Special Medicfill Plan is considered a Medigap plan and requires enrollment in original (traditional) Medicare.
  • Medicare does not permit a Medigap plan to pay for a Medicare Advantage plan’s co-pays, deductibles, or premiums. Please refer to Medicare.gov for additional information on Medigap and Medicare Advantage Plans.
  • If your spouse is only offered a Medicare Advantage plan through their former employer/retirement benefits and they are paying 50% or less of the monthly premium, then your spouse must enroll in the Medicare Advantage plan.
Yes, if your spouse is provided health coverage through either active employment or retirement. Your spouse must enroll in that coverage unless your spouse is responsible to pay more than 50% of the total monthly premium, for the lowest active or retiree health benefit plan available, even if the coverage is provided through a third party. This includes Medicare supplement plans or cash benefits in lieu of enrollment in a health plan (also known as stipends). Please visit https://dhr.delaware.gov/benefits/cob/pensioners.shtml for information.
Yes, Medicare is considered a change in insurance. A new electronic Spousal Coordination of Benefits (SCOB) form is required to be completed within 30 days of a spouse’s employment or insurance status change.

Please visit https://cob.dhr.delaware.gov/ and complete a new form prior to sending a copy of your spouse’s Medicare card or enrollment verification.

  • Once your spouse is enrolled in the Medicare supplement plan and you have submitted a SCOB form informing if he/she is enrolled in another supplement coverage, you do not need to resubmit annually during the open enrollment period. If your spouse obtains other insurance coverage, you do need to report the change by submitting an online SCOB form within 30 days of obtaining other coverage.

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State of Delaware Office of Pensions
McArdle Building, 860 Silver Lake Blvd., Suite #1
Dover, DE 19904-2402
Toll Free: (800) 722-7300, Local: (302) 739-4208

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