Coordination Benefits

Generally you are eligible for Medicare if you or your or spouse worked for at least 10 years in Medicare covered employment and you are 65 years or older and a citizen or permanent resident of the United States. (Go to www.medicare.gov for other certain circumstances.)

 

There are two (2) parts to Medicare.

 

  • Medicare Part A is Hospital insurance – Most people get Part A automatically when they turn age 65. You do not have to pay a monthly premium.

 

  • Medicare Part B is Medical insurance – There is a standard monthly premium. (Go to www.medicare.gov for the current year’s premium.) If you do not choose Part B when you first become eligible at age 65, the monthly premium may be increased. (Go to www.medicare.gov for additional information.)

 

Failure to Enroll in Medicare
If a Covered Person is eligible for Part A and/or Part B of Medicare, but does not enroll in one or both parts, the benefits payable under this Plan will be reduced by the amount he would have received if he had actually enrolled. A Covered Person is considered eligible for Medicare on the earliest date any coverage under Medicare could become effective for him. It is important to enroll in Medicare as soon as you are eligible, so that you do not lose any benefits the Plan would otherwise pay.

 

Coordination of Benefits (COB) with Medicare.
Except as otherwise stated in the Plan Document, Medicare will be primary and this Plan will be secondary.

 

Active Employees Medicare-Eligible Due to Age.
If a covered active Employee (or his Dependent) is eligible for Medicare due to age, this Plan will continue to be primary coverage for that covered Employee or Dependent, provided the Employee remains working.

 

Always remember to ask your medical provider/hospital/facility if they are a Medicare provider/hospital/facility.

Examples of the Coordination of Benefits (COB) circumstances with the OU Health Plan and Medicare.

 

Medical, Hospital, Laboratory charges –

The order in which a claim would be paid if:

 

  1. Member is retired, with family plan, and on Medicare, spouse is retired with no other coverage through his/her employment and on Medicare – Medicare is then primary for both with the OU Health Plan being secondary.
  2. Member is actively employed, with a family plan, spouse is on Medicare (and has no other coverage through his/her employment) – OU Health Plan is primary for active member and spouse, with Medicare secondary for the spouse.
  3. Member is retired, with family plan, and on Medicare, spouse is actively employed with family plan and not Medicare eligible, Spouse’s active plan is primary for OU member and Medicare is second, OU Plan is tertiary.
  4. Member is retired, with family plan, and on Medicare, spouse is actively employed with a family plan, and is Medicare eligible; a) Spouse’s plan is primary for the OU Health member, Medicare is second, OU Health Plan will be tertiary, b) Order of benefits for spouse under the OU member’s plan: Spouse’s active plan is first, Medicare is second (if spouse does not enroll in Medicare, OU Plan will estimate Medicare’s responsibility), OU Plan is tertiary.

 

 

Remember:
Medicare has an annual deductible. (Go to www.medicare.gov – “Medicare Costs at a Glance” – for the current year’s deductible.) The OU Health Plan has an annual deductible of $300 for Individual and $800 for Family. The amount applied to the Medicare deductible is also applied to the OU Health Plan deductible. Once you have met the OU Health Plan’s annual deductible, the Plan will then pay as secondary coverage. (See exceptions in C and D above.)

 

When Medicare is primary, they pay first. The balance will then be paid by the OU Health Plan at 20% (after the member has met the annual deductible). The member is then responsible for the remainder of the bill. Wait until you have received a bill from the provider before paying the balance.

 

Laboratory Benefits

When Medicare is primary, be sure to use a laboratory or radiology facility that takes Medicare. You do not need to choose In-Network OU Health Plan providers or Out-of-Network providers.

 

Go to www.medicare.gov for more in-depth information on Medicare benefits.

 

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