Health and Welfare Summary Plan Description
4.5 Medicare
- Overview. Medicare is the health insurance program for people age 65 or older, certain people with disabilities who are under age 65, and individuals with permanent kidney failure. Medicare Part A is hospital insurance, Medicare Part B is insurance for physician services, out-patient care, durable medical equipment, home health services and other medical services, Medicare Part C is a private insurance program called Medicare Advantage (which generally allows HMOs to cover Medicare-eligible individuals at a lower cost to the HMO), and Medicare Part D is insurance for pharmacy benefits. Medicare Part A is primarily financed by payroll taxes, while Parts B, C and D are financed primarily by premiums paid by those who choose to enroll. For enrollment and eligibility information, call Social Security at (800) 772-1213 and check the Internet at medicare.gov. Generally, if you are receiving Active Coverage, you are not required to enroll in Medicare in order to continue to participate in the Plan. If you are a Retiree and wish to continue to participate in the Plan, you must enroll in Medicare, as explained in subsection (b), and you may select from the Self-Funded PPO or Kaiser HMO benefit options described in Section 6.1.
- Retirees in Self –Funded Plan Must Enroll in Parts A and B. If you are a Medicare-eligible Retiree who is enrolled in the Self-Funded PPO, you must enroll in Medicare Parts A and B. The Plan will pay your medical claims on the assumption that you have full Medicare coverage under Parts A and B, regardless of whether you have actually enrolled for the full coverage. So, failing to enroll in Medicare Parts A and B will result in you having to pay substantially higher out-of-pocket costs for health care services, including increased premiums. The same rule applies for your Medicare-eligible Dependent unless your Dependent continues working and has health care benefits through his or her own employer's group health plan. If your Medicare-eligible Dependent continues working but has Retiree coverage under this Plan through you, the he or she must enroll in Parts A and B when you enroll in these programs or else risk increased Medicare premiums. Out-of-pocket charges resulting from failure to enroll in Medicare Parts A and B will not apply towards your maximum calendar year out-of-pocket limit under Section 8.6(c).
- Retirees in Kaiser HMO Must Enroll in Part C. If you are a Medicare-eligible Retiree who is enrolled in the Kaiser HMO, you must enroll in your HMO's Medicare Part C program as soon as you are eligible. If you do not enroll, you will pay the difference between the regular (non-Part C) premium charged the Plan by the HMO over the significantly lower Part C premium that the Plan would have been charged by the HMO. Blue Shield does not have a comparable Part C Plan. If you are enrolled in the Blue Shield HMO at the time you become eligible for Medicare, you will be transferred to the Self-Funded PPO unless you choose to be enrolled in the Kaiser Senior Advantage Plan.
- Part D Prescription Drug Program.Medicare-eligible Retirees are eligible for a prescription drug program under Medicare Part D and are automatically enrolled by the Plan and will be charged a premium by Medicare. Retirees covered under the Self-Funded PPO or an HMO are not covered under the Plan's prescription drug plan. While the Plan has automatically enrolled in Medicare Part D, you still must enroll in both Medicare Parts A and B to receive full coverage in the Plan.
- End-Stage Renal Disease. If you are diagnosed with End-Stage Renal Disease ("ESRD"), you may be eligible for Medicare. If you are eligible for Medicare due to ESRD, you must apply to receive full benefits because enrollment for Medicare benefits is not automatic. This Plan coordinates ESRD benefits with Medicare. If you do not enroll in Medicare as soon as you are eligible, the Plan will not cover the portion of your expense the Medicare would have paid. As soon as you are eligible for Medicare, please enroll and notify the Plan Office immediately.