Medicare Coverage and Coordination
If you have both this group coverage and Medicare, federal rules determine which plan pays first. These rules apply to the working aged, the disabled, or patients with end stage renal disease (ESRD). For The working aged and disabled, these rules take into consideration and employment status of the employee covered by the employer group health plan as well as the number of part-time and full-time employees of the employer group health plan.
If your employer or group employs 20 or more employees and you are 65 years or older and eligible for Medicare only because if your age, this coverage will pay before Medicare, as long as your coverage is based on your status as a current active employee or the status of your spouse as a current active employee.
If your employer or group employs 100 or more employees and if you are under 65 years and eligible for Medicare only because of a disability (and not ESRD), this plan pays first before Medicare as long as your group coverage is based on your status as a current active employee, or the status of your spouse as a current active employee, or the current active employment status of the person for whom you are a dependent.
If you are under age 65 years and eligible for Medicare only because of end-stage renal disease (ESRD), coverage under this plan is not applicable since we do not cover end-stage renal disease or related treatment including dialysis.
When Medicare is allowed by law to be the primary payer, coverage under this plan will be reduced by the amount paid by Medicare for the same covered services. Benefits under this plan will be paid up to either the Medicare-approved charge for services by a Medicare participating provider, or the lesser of our eligible charge or the limiting charge (as defined by Medicare) for services rendered by a provider who does not participate in Medicare.
If you are entitled to Medicare benefits, we will begin paying benefits after all Medicare benefits, including all lifetime reserve days are exhausted.If you have coverage under Medicare Part B only, we will pay inpatient benefits based on our eligible charge less any Medicare Part B benefits for inpatient diagnostic, laboratory and radiology services.
When services are rendered by a provider or facility that is not eligible or entitled to receive reimbursement from Medicare, and Medicare is entitled by law to be the primary payer, we will limit payment to the amount that would have been payable by Medicare had the provider or facility been eligible to receive such payments, regardless of whether or not Medicare benefits are paid.
If you and/or your spouse has Medicare coverage (either Part A or Part B), please be sure to notify NetCare’s Customer Service Department as soon as possible. This will ensure that proper coordination of benefits.