State of Kansas Health Care Commission

Direct Bill/Retiree Health Plan Frequently Asked Questions

Q. I’m retired and becoming eligible for Medicare. Is it possible to keep the State health plan as primary?

A. No. All State of Kansas Health Plans have a Medicare Exclusion Rider. This means that what Medicare paid (or would have paid if you had enrolled) is subtracted from the total bill submitted by the provider. What is left is processed just like any other claim -- subject to the deductibles and copayment requirements of the plan. 

Due to the Medicare Exclusion Rider it is very important that you enroll in both Part A and Part B of Medicare when you are retired or no longer actively employed. The retiree will be responsible for any plan deductibles, coinsurance, copayments and the portion of the claims that would have been covered by Medicare had they enrolled. This applies even if the retiree is not entitled to free coverage of Part A and/or must pay additional fees for Part B.

Q. I did not take out Part B of Medicare when I was first eligible and now my state health plan is not paying claims---what do I do?

Contact your local Social Security office immediately to see when you will be able to enroll in Part B. Until you are enrolled in Part B, you are responsible for amounts that Medicare would have paid.

Q. My spouse is still an active employee (another employer) but is covered on my state health plan. He/she will be turning 65 soon. Does he/she need both parts of Medicare at this time?

A. This depends on whether you are an active employee or a retiree. If you are an active employee, your spouse can waive or suspend Part B of Medicare coverage until you retire because Medicare will pay secondary. If you are a retiree, your spouse will need to enroll in Medicare Part B when first eligible in order to have full coverage under our health plan.

Q. I am covered by Medicare, state health plan and my spouse’s insurance at work. Which one should pay primary?

A. If you are an active employee, the State plan will pay primary on you, your spouse’s plan will pay secondary and Medicare would consider anything left after the other plans have paid. If you are a retiree, your spouse’s plan would pay primary because that plan is directly related to his/her status as an active employee. Medicare would pay secondary and the State plan would consider any balances after the other two had processed the claim.

Q. I will be turning 65 soon, but my spouse will not be 65 for several years. What happens to his/her coverage if I terminate my State coverage?

A. Your spouse is only eligible to be covered as your dependent. If you leave the State group your spouse will also leave the State group. This is a COBRA qualifying event as long as you terminate your state coverage when you first become Medicare eligible.  Your spouse will be offered COBRA coverage for 36 months. The one exception for a spouse to remain eligible to participate is for a "surviving spouse." If you die and your spouse was covered by your State of Kansas health plan, your spouse will be classified as a "surviving spouse" and will be able to continue to participate in the State of Kansas health plan for as long as he/she continues to pay the premium.

Q. I have heard about Kansas Senior Plan C.  What kind of coverage is this and when would I be eligible to enroll?

A. Kansas Senior Plan C is a Medicare Supplement plan exclusive to participants in the State of Kansas Health Plan.  The medical portion of this coverage provides the same benefits as any Plan C supplement sold to Medicare eligible persons.  Unlike most Plan C Medicare Supplements, the Kansas Senior Plan C includes prescription drug and dental benefits.  To be eligible to enroll in this plan, a participant and any covered dependents must be Medicare eligible and have both Part A and Part B of Medicare.  A participant can change to this coverage either during Open Enrollment or during the year with a qualifying event, by calling our toll free number 1-866-541-7100.

Q. I am already retired and turning 65 in a few months. What kind of paperwork is needed for me to continue with the State of Kansas Health Plan?

A. About one month before you or your covered spouse turn 65, the State of Kansas will send you a form to complete. Make sure you write your Medicare number on the form, as well as submit a copy of your Medicare card. The State of Kansas will verify your enrollment in Part A and Part B. You will just need to add the Medicare information to the form, sign it and return it to the State of Kansas.  If you are eligible, you will be offered the Kansas Senior Plan C.

Q. How do I know if I am enrolled in both parts of Medicare?

A. Your Medicare card will indicate the coverage you have and the dates it became effective. It is very possible for Part A and Part B to have different effective dates -- particularly if you work beyond your 65th birthday. Part A is called "Hospital Insurance" on your card and Part B is called "Medical Insurance."

Q. I will be going on vacation and I will be out of the country. If I should need medical care will my State Health Plan pay? Will Medicare Pay?

A. Medicare pays for very few claims outside the United States and only in very special circumstances. You can get more information about this from your Medicare Handbook or the Medicare web pages. However your state health plan provides the same benefits to retirees as to active employees and will cover claims incurred outside the United States according to plan guidelines. For HMOs, generally this means the initial treatment of an emergency or urgent situation only.  Kansas Senior Plan C also offers some limited coverage for persons traveling outside of the United States.  The Foreign Travel Emergency Benefit has a $250 deductible and then pays 80% of medically necessary and appropriate care to a maximum of $50,000 per person.

It is important to remember that, generally, the providers you use when outside the US will not be participating providers with your health plan. You will be responsible for paying the bill and filing a claim with your plan for reimbursement. All claims must be translated into English with sufficient detail for the health plan to know what services were actually performed. Also, remember that some medications which require a prescription in the US are available over-the-counter in Europe, and some things that require a prescription in Europe are available over-the-counter here. When filing claims for medications purchased outside the US, please provide the US equivalent name of the product (you will need to ask the pharmacist for this information). AdvancePCS will only pay for items that would have been covered had they been purchased in the US.

Q. I will be going on vacation for several months. Will I be able to get a large enough supply of my prescription medications to carry with me?

A. If you are traveling in the US, your drug card is good anywhere you travel so you will not need to carry the medications with you. When you use a national chain pharmacy (such as Walgreen’s, OSCO or Eckard) the pharmacy can transfer your prescription from one location to another. If you use a small independent pharmacy, you will need to carry your prescription with you. The new drug plan design will allow you to get two refills at one time for up to a 60-day supply of medication. If you want more than 60-days, you will need to pay cash for the excess medications and file a paper claim to AdvancePCS requesting reimbursement for the additional medications which you purchased.

If you wish, you may forward your prescriptions to a different address.  This can be done online or by calling the number on your prescription drug card.

Q. Who do I call if I have questions about my coverage or how my claims are being paid?

A. Questions about specific coverage items or how claims were processed should be directed to the Health Plan. The telephone numbers are in your Open Enrollment book as well as on the back of your ID cards.

Q. Who do I call if I want to change my Primary Care Physician (PCP).

A. Members enrolled in one of the HMOs may call the health plan to change their PCP. Members enrolled in one of the PPOs do not need to designate a PCP.

Q. Who do I call if I need to make a change of address or to drop coverage on a spouse or dependent?

A. Write to the State of Kansas Benefits Administration office at 900 SW Jackson, Room 920-N, Topeka, Kansas 66612-1251.  Please be sure to include your name, social security number and telephone number, including area code.  Or you may call toll-free 1-866-541-7100 and a staff member will help you.

If you are moving out of the area and are enrolled in an HMO then you will also need to change your enrollment.

Q. My spouse, who is currently covered under my state retiree health plan, has been offered insurance at his/her place of employment. If I drop them from the State group can I add them back on at a later date?

A. Yes.  Open Enrollment is held each October to allow plan participants to make the changes appropriate for their situations. In addition, there are certain situations which will qualify for mid-year changes, allowing you to add dependents to your coverage at times other than Open Enrollment. Any changes due to a life-status change event must be made within 31-days of the event – so within 31-days of the loss of coverage by your spouse.

Q. When I die, is my spouse eligible to continue with the State Health Plan?

A. Yes,  if your spouse is enrolled in the coverage at the time of the your death.  Your surviving spouse should call the State of Kansas at 1-866-541-7100 or write to the State of Kansas Health Benefits office at 900 SW Jackson, Room 920-N, Topeka, Kansas 66612-1251 with documentation of the participant's death.  State of Kansas will verify the surviving spouse's name, date of birth, social security number, address, primary care physician, if needed, Medicare info, if needed and method of payment.  The spouse's coverage would begin the first of the month following the member's death.  

Q. I just received my Medicare card and I am not age 65 but I am disabled. What do I need to do?

A. You will need to send a copy of your Medicare card to the State of Kansas Health Benefits office at 900 SW Jackson, Room 920-N, Topeka, Kansas 66612-1251. You will receive a form to sign showing Medicare is primary and the State will be the secondary payor. You will need to be sure and have both parts of Medicare to have full coverage.  At this time you would be offered Kansas Senior Plan C, if you are eligible.

Q. I tried to get a prescription filled and was told my coverage has been canceled. What do I do?

A. Call the State of Kansas at 1-866-541-7100 or in Topeka at 785-296-1715, staff will check our database to make sure your coverage is active.  The prescription drug carrier will then be contacted to verify and update your coverage if necessary.  Once the issue is resolved, a staff member from the State of Kansas will return your call.

Q. I called my medical carrier and was told my coverage was canceled. I have been paying the premiums. What do I do?

A.  Call the State of Kansas at 1-866-541-7100 or in Topeka at 785-296-1715, staff will check our database to make sure your coverage is active.  Once the issue is resolved, a staff member from the State of Kansas will return your call.

Q. I want to cancel my State medical insurance, but I want to keep just the prescription or dental or vision coverage. Can I do this?

A. You must be enrolled in medical to have dental and prescription drug benefits. However, since the vision plan is totally voluntary, you may be enrolled in it without the health coverage.

Q. Which plan will I enroll in if I am retired and under 65?

A. You may enroll in Kansas Choice, Kansas Prefer, Preferred Health Systems, regardless of where you live or any of the HMO’s that are offered where you reside.

Related Links:

-Direct Bill
-Documents
-Employee Advisory Committee
-Non-State Groups
-HCC Meetings
-Health Care Providers for State of Kansas Participants

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Contacts during 2006 Direct Bill Open Enrollment for PY2007: 

Deb Dumas 1-785-296-1715 or
Toll Free:  1-866-541-7100; or
Email: deb.dumas@da.state.ks.us

Documents:

2007 Open Enrollment Booklet for Direct Bill Participants PDF version

2007 Comparison Chart PDF version

2006 Open Enrollment Booklet for Direct Bill Participants [PDF version]