Covered Expenses must first be submitted to Medicare. When you receive the “Explanation of Medicare Benefits” (EOMB) statement which shows how much Medicare paid, submit a copy of the Covered Expenses together with a copy of the Medicare EOMB statement to the Plan.
First, the Plan will calculate what our “normal benefit payable” would be in the absence of Medicare coverage. Then, from our “normal benefit payable,” we will deduct the benefit paid by Medicare and then also deduct the annual out of pocket deductible and out of pocket limits that apply under this Plan. The out of pocket limit will not be charged against inpatient hospital stays. For an inpatient hospital stay, once your $200 deductible is met under the Plan, the Plan will then pay 70% of the Medicare inpatient deductible. The Plan will pay only the difference between our “normal benefit payable” and the benefit paid by Medicare.
It is important to remember that the Plan will not pay more than our “normal benefit payable,” which is the amount the Plan would have paid in the absence of Medicare coverage. If the Plan’s “normal benefit payable” and the benefit paid by Medicare are the same amounts, or if the benefit paid by Medicare is more than the Plan’s “normal benefit payable,” the Plan will not pay any additional benefits. The combination of the Plan’s “normal benefit payable” and the benefit paid by Medicare will never exceed what the Plan would have paid in the absence of Medicare coverage.
Coordination with Medicare Part A (Medicare Hospital Insurance for an Out Of Area Hospital)
Example 1 |
Inpatient Hospital Charges |
$10,000.00 |
| Medicare Pays |
9,008.00 |
| Medicare Part A Deductible |
992.00 |
| Plan pays 70% of deductible* |
694.40 |
| Participant Balance |
297.60 (applied to annual out-of-pocket limit) |
Coordination with Medicare Part A (Medicare Hospital Insurance for a Preferred Provider Network Hospital)
Example 2 |
Non-Preferred Inpatient Hospital Charges
|
$10,000.00
|
| Medicare Pays |
9,008.00 |
| Medicare Part A Deductible |
992.00 |
| Negotiated Rate of 20% |
198.40 (member not responsible for this amount) |
| Allowed amount (negotiated rate) |
793.60 |
| Plan pays 80% of negotiated rate |
637.88 |
| Participant Balance |
158.72 (applied to annual out-of-pocket limit) |
Coordination with Medicare Part A (Medicare Hospital Insurance for a Non-Preferred Hospital In Area)
Example 3 |
Inpatient Hospital Charges
|
$10,000.00 |
| Medicare Pays |
9,008.00 |
| Medicare Part A Deductible |
992.00 |
| Separate $1,000 deductible |
992.00 |
| Plan Pays |
.00 |
| Participant Balance |
992.00 (not applied to annual out-of-pocket limit) |
Coordination with Medicare Part B (Medicare Medical Insurance)
Example 4 |
Preferred Hospital outpatient charges
|
$500.00 |
| Medicare Pays 80% |
400.00 |
| Copayment after Medicare pays |
100.00 |
| Negotiated rate, 20% of copay amount |
20.00 (member not responsible for this amount) |
| Allowed amount (negotiated rate) |
480.00 |
| Normal Plan benefits 80% |
408.00 |
| Deduct what Medicare pays |
<400.00> |
| Plan pays |
8.00 |
| Participant Balance |
72.00 (applied to annual out-of-pocket limit) |
Coordination with Medicare Part B (Medicare Medical Insurance)
Example 5 |
Physician Charge for Office Visit
|
$120.00 |
| Medicare Pays 80% |
96.00 |
Normal Plan Benefits 70%
|
90.00 |
Plan pays
|
0.00 |
| Participant Balance |
24.00 (applied to annual out-of-pocket limit) |
Coordination with Medicare Part B (Medicare Medical Insurance)
Example 6
|
Physician Charges for Office Visit
|
$120.00
|
Medicare Pays 80%
|
96.00 |
| Normal Plan Benefits when Out-of-
Pocket Maximum has been met |
120.00 |
| Plan pays |
24.00 |
| Participant Balance |
0.00 |
| *The Plan pays 80% of the UCR charges when a preferred hospital is used. |
