Navigating Medicare for Working Women

Coverage considerations include employer size, whether their employer lets them stay in the group plan, and their health issues.

By Diane Omdahl
Diane Omdahl
Diane Omdahl

It’s important for any woman approaching age 65 to understand how Medicare addresses her specific healthcare needs. However, women who are still working may have additional questions and considerations. As a Medicare expert with over 30 years of experience, I understand how crucial it is for these women to know how Medicare works and its implications for their healthcare coverage during retirement.

This article explores the considerations surrounding employer insurance, healthcare-provider relationships and women’s specific healthcare needs. Sharing this knowledge will your female clients who are working will help them make informed decisions and ensure seamless healthcare coverage as they transition into retirement. (If Medicare is on your client’s horizon and she doesn’t have a long work history, please see here for additional information.) This article will also help your male clients approaching 65 and still working.

Let’s get into it!

Over age 65 and employer insurance?

Women who turn 65 and are still working must get answers to two important questions. Can they continue with the employer group health plan? And, must they enroll in Medicare?

The answers to both questions hinge on whether the employer plan will be the primary or secondary payer, and that depends on the number of employees in the company.

Large-employers only

If the employer has 20 or more employees (considered a large employer), the group health plan is the primary payer. That insurer pays a medical bill first, up to its limits of coverage. The employer cannot change its rules for the employee or the employee’s Medicare-eligible dependents. The company cannot drop the coverage, charge higher premiums, or require enrollment in Medicare.

“Contrary to popular opinion, there is no requirement to enroll in Medicare for those who are not receiving Social Security benefits.”

Essentially, it’s as if the 65th birthday never happened. If your client is not already receiving or doesn’t plan to sign up for Social Security retirement benefits, she or he can choose to delay Medicare enrollment and will have an opportunity to enroll, without penalty, when retiring. Contrary to popular opinion, there is no requirement to enroll in Medicare for those who are not receiving Social Security benefits.

Even though there is no requirement, Social Security recommends enrolling in Part A, hospital insurance. It is premium-free and can help with costs for hospitalization and a few other services. Enrolling in Part B, medical insurance, is not recommended for individuals who are still working and insured by thehir employer’s large-group plan. It comes with a monthly premium, may not do much to enhance coverage, and can jeopardize future Medicare options.

Small employers are a different story

On the other hand, if the employer has fewer than 20 employees (a small employer), the rules change. It is up to the company to decide whether employees can continue with the group plan after age 65. If the employee is allowed to keep this coverage, Medicare laws dictate that the employer plan becomes the secondary payer to Medicare. In either situation, enrollment in Medicare Part A and Part B becomes necessary.

For those who can continue with the employer plan, there is a third question to answer: Do you continue with the plan or choose Medicare? Consider these factors when making your decision:

  1. Cost of the employer group health plan (EGHP). Determine whether Medicare offers a better deal overall. Conducting a cost-benefit analysis can help the employee make an informed decision.
  2. Medicare costs. Besides the Part B monthly premium, Medicare supplement, Medicare Advantage, and Part D drug plans can also come with premiums. Higher-income beneficiaries also pay more when subject to IRMAA (income-related monthly adjustment amount). Learn more here.
  3. Health savings account (HSA) contributions. Once enrolled in Medicare, individuals are no longer eligible to contribute to an HSA.
  4. Medications. Enrolling in Medicare may render individuals ineligible for certain drug discount programs. It’s essential to consider the cost implications, as some medications can become significantly more expensive without these discounts.
  5. Dependents. Medicare is designed as a one-person, one-package deal, meaning it typically covers only the individual enrolled. Evaluate the coverage needs and options for dependents relying on the employer plan.

Note: The information provided here is a general overview and may vary based on specific circumstances and whether the employer plan is the primary or secondary payer to Medicare. It’s advisable to consult with a knowledgeable Medicare professional.

Healthcare provider considerations under Medicare

Because of specific healthcare needs, there’s one question at the top of the list for many women: “Will I have to change doctors once I enroll in Medicare?”

The two common options for Medicare coverage in retirement deal with physicians differently.

  • Original Medicare with a Medicare supplement insurance plan (also known as a Medigap policy): With this coverage, beneficiaries can see any provider in the United States or its territories that accepts Medicare assignment (basically Medicare payment). These providers do not have to see every patient, but for those they see, they must submit the claim to Medicare and can charge no more than Medicare allows. Most physicians (99%) continue to see Medicare patients, making it likely that individuals opting for Original Medicare will experience minimal changes, with the payer source transitioning to Medicare.
  • Medicare Advantage plan: These plans are network-based, so those who elect this coverage may need to change doctors. Some plans, such as PPOs (preferred provider organizations), provide flexibility to see out-of-network providers, but these services often cost more. Plus, doctors not contracted with a particular Medicare Advantage plan do not have to provide services to that plan’s members. Except in true medical emergencies, healthcare providers have no obligation to see non-members.

Medicare and women’s specific healthcare needs

Medicare covers healthcare services that are deemed reasonable and necessary for diagnosing and treating medical conditions. Since women’s healthcare needs during retirement may not always differ significantly from those of men, Medicare covers a range of conditions commonly associated with older age. These include cataracts, cancer, osteoarthritis, chronic obstructive pulmonary disease, diabetes, heart disease and depression.

In addition to covering medically necessary care, Medicare includes coverage for various preventive services. This encompasses flu and pneumonia vaccinations, Covid boosters, colonoscopies, and specific services tailored to women, such as mammograms and pelvic exams.

It’s important to note that as individuals age, chronic diseases can become more prevalent, and long-term care is a significant concern for everyone, but more so for women. They tend to live longer than men and often become caregivers for parents and spouses. It’s crucial to note that Medicare does not cover long-term care, which is why it is crucial for women to have a long-term care plan before age 65. For more information on this topic, you can refer to this article as a resource.

Working women transitioning to Medicare must understand the interplay between employer insurance and Medicare. They must carefully evaluate many factors, including employer size, cost considerations and coverage of their specific healthcare needs. By navigating these concerns effectively, working women can make informed decisions about their Medicare options and ensure comprehensive healthcare coverage during retirement.

Diane Omdahl, a registered nurse, has been a trailblazer in the Medicare industry for over 30 years. She started her first company in the basement of her home and developed it into a multi-million-dollar organization providing Medicare-related training and tools for home health agencies and long-term care facilities. Diane now operates 65 Incorporated and i65, providing unbiased and expert Medicare enrollment guidance to seniors, their families and professional advisors. She recently published “Medicare For You: A Smart Person’s Guide.”



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