Migliaccio & Rathod LLP is investigating whether certain employer health plans improperly reduced or denied coverage for Medicare-eligible employees or spouses who remained covered through current employment.
People often assume that turning 65 automatically means Medicare must become their primary health insurance. That is not always true. Federal Medicare Secondary Payer rules can prohibit certain employer plans from treating Medicare eligibility as a reason to provide worse coverage to an actively employed worker or the worker’s spouse.
We are investigating employers and health plans that may have required active employees or their spouses to enroll in Medicare, treated Medicare as primary solely because a person turned 65, or denied claims because an eligible person had not enrolled in Medicare.
You May Be Affected If:
- You or your spouse were age 65 or older;
- You had health coverage connected to current employment, rather than solely as a retiree;
- The employer generally had 20 or more employees;
- Your employer or health plan told you that you or your spouse had to enroll in Medicare;
- Your employer plan began treating Medicare as the primary payer when you or your spouse turned 65;
- Claims were denied because you had not enrolled in Medicare Part A or Part B;
- You were encouraged or financially pressured to drop the employer plan because you became eligible for Medicare; or
- You incurred medical bills or Medicare premiums because of the change.
Retiree health plans and COBRA coverage are subject to different rules, so this investigation is particularly focused on coverage tied to current employment.
Why This Matters
For qualifying active workers and spouses, Medicare eligibility alone may not permit an employer health plan to shift responsibility for medical costs to Medicare.
Potential problems may include:
- requiring enrollment in Medicare as a condition of keeping employer coverage;
- denying claims because Medicare was not obtained;
- paying claims only after assuming Medicare should have paid first;
- charging additional amounts based on Medicare status; or
- offering financial pressure intended to move older workers or spouses off the employer plan.
These practices can leave employees paying Medicare premiums they did not expect or facing substantial medical bills when claims are denied.
Does This Apply to Your Health Plan?
This investigation is particularly focused on health coverage connected to current employment with a private-sector employer.
The employer plan will ordinarily also need to be governed by ERISA. In practical terms, that generally means coverage through a private company or nonprofit rather than a federal, state, county, city, public-school, or other governmental employer. Certain church plans are also excluded.
If you are unsure whether your employer or plan qualifies, we can generally determine that from basic employment and insurance documents.
We Are Interested in Hearing From Employees and Spouses Who:
- were told they had to enroll in Medicare at age 65;
- were actively employed, or covered through an actively employed spouse, at the time;
- had employer health claims denied because Medicare supposedly should have paid first;
- were required to enroll in Medicare Part A or Part B to maintain employer coverage;
- were offered money or another incentive to leave the employer plan;
- paid Medicare premiums because of an employer requirement;
- incurred medical expenses after the employer plan reduced or denied benefits; or
- have letters, EOBs, plan documents, emails, or benefits materials describing the Medicare requirement.
If your employer health plan required you or your spouse to shift to Medicare while coverage was still tied to current employment, we would like to hear from you. Please complete the contact form on this page, send us an email at [email protected], or call us at (202) 470-3520.