Group health insurer requires Medicare

G

Goodfootdoug

New Member
My small group health insurer has been my primary without need for Medicare. Now they are requiring me to get Medicare Part B, and Medicare will be primary, group health will be secondary. The employer says the monthly premium, for group health, will not change. Why does the rate not decrease? The insurer will now only be paying roughly 20% of my claims, whereas before they paid 100% for the same premium.
The law requires an 80% loss ratio. If the premium for my group health as primary, paying 100%, satisfied the 80% loss ratio requirement, how can the greatly reduced coverage with the same premium meet the 80% requirement?
 

I see your point, and I definitely do not know the answer to your question;

but I would just offer 2 thoughts on that general situation.

1) Perhaps it helps them to keep having medical coverage available overall, or it might even enable them to provide the group insurance, for everyone that gets it,
to require that those who do qualify for Medicare, take it when they qualify.
And/Or, another possible view:
2) it is actually good insurance coverage, I think, to have them both, Medicare Part B and your other medical insurance plan. The combination will likely serve you well. Something many of us would like to have.

I don't know the rest of your question. I am not an expert at all.

But, maybe it was an extra good deal, for the younger ones who do not qualify for Medicare, and for you then in the past years, when you benefitted from it, too.
 
Last edited:
Another possibility related to your question,
might be something related to the requirements of a small group plan, rather than for each individual under the plan having a separate requirement of that 80% loss ratio.

Again, I have no training in the field. I am just pondering and sharing ideas, which is what we do on this sort of forum. We don't and can't give professional advising.
 

I paid nothing for Aetna HMO via the State of N.J. employees then retirees benefits programs (SHBP) until I got on Medicare, at which time I started paying the basic Medicare premiums. SHBP required that I submitted proof of Medicare B coverage (what then was the red, white and blue card) to add me to their Medicare plan which is basically an advantage plan. Once I did that, the transition was seamless but just the opposite scenario from yours. Aetna Medicare HMO (and as of this year PPO) is my primary insurance and I was instructed to never use that red, white and blue medicare card as soon as they provided Medicare coverage for me.

I can't answer your questions either. Perhaps a group insurance representative can answer those questions for you.
 
While my spouse worked, our health insurance for both of was about $130/mo. As each of us turned 65, Medicare became the primary and the private insurer became secondary.

We still pay the private carrier, plus the Medicare premiums on each of us.

Our coverage is exactly the same. But we get to pay 3x what our previous bill was!

OTOH, that is still only about 45% of what our HMO would normally charge on a policy for 2 seniors. It's the equivalent of a Medicare Advantage plan, since the HMO has its own hospitals, pharmacy, complete vision and hearing aid departments, etc. - everything but dental is included.
 
Hi. Recently retired (January of 2023). I maintained health coverage through my employer (a large county government). The cost was $198 for family coverage (spouse and dependents). Now that I have retired I have taken the employer-provided plan at $197 per month. The plan only covers me, and my wife is now covered under her employer plan.

My employer-provided plan names the private carrier as primary, and Medicare as secondary. I now have both Part A and Part B under Medicare with a Part D plan included in the private plan. I had to secure a dental insurance plan from another source at about $50 per month. In all, I'm paying $411 a month for coverage that used to cost me $197 (a $214 increase).

Yes, I could have opted for a Medicare "Advantage" plan (I have an issue with the use of the word advantage with these plans, but that's a rant for another day), but my employer-sponsored plan has much better coverage (85%/15%). Can't beat it.
 
Welcome, @Christopher :)

That's good that you have plans that cover your needs, and your wife, and that you like. And that you are successfully managing the transitions.

I don't remember any employer plans which would pay before Medicare, though perhaps it's because it is some type of city government, or of course, there could easily be other things that I hadn't encountered! :giggle:

Some of our members have and like their "advantage" plans....while many of us, as you do, prefer not to have those.
 
Kaila said:
Welcome, @Christopher :)

That's good that you have plans that cover your needs, and your wife, and that you like. And that you are successfully managing the transitions.

I don't remember any employer plans which would pay before Medicare, though perhaps it's because it is some type of city government, or of course, there could easily be other things that I hadn't encountered! :giggle:

Some of our members have and like their "advantage" plans....while many of us, as you do, prefer not to have those.
Click to expand...
Hi. I actually read through much of the county-sponsored plan to determine which plan (private or Medicare) is considered primary. The language was particularly dense, but ultimately, I was able to determine that the private plan is primary.

On the related note, the medical advantage plans (sanctioned by Medicare so a shout-out for the insurance industry lobbyists) are just HMO plans that require networks, prior authorization for certain treatments, unlimited out-of-pocket costs, require that the health provider you use be in network to avoid significant upcharges, and offer financial incentives to physician "cost-saving" decisions which I feel might constitute a conflict of interest related to proper healthcare.

Of course, these plans are advantageous... to the insurance company. But, to each his/her own.
 
However, after further review of the Medicare site it's so hard to tell whether my retirement carrier is primary or secondary. I'm going to wait until I receive the actual policy from the retirement carrier.
 


Back
Top