2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 9. Coordinating Benefits With Medicare and Other Coverage
When you have Medicare
The Original Medicare Plan (Part A or Part B)
Section 9. Coordinating Benefits With Medicare and Other Coverage
When you have Medicare
The Original Medicare Plan (Part A or Part B)
• The Original Medicare Plan (Part A or Part B)
The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.
All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. For example, you must continue to obtain prior approval for some prescription drugs and organ/tissue transplants before we will pay benefits. However, you do not have to precertify inpatient hospital stays when Medicare Part A is primary (see page 21 for exceptions).
Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.
When we are the primary payor, we process the claim first.
When the Original Medicare Plan is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for the covered charges. To find out if you need to do something to file your claims, call us at the customer service phone number on the back of your Service Benefit Plan ID card or visit our website at www.fepblue.org.
We waive some costs if the Original Medicare Plan is your primary payor – We will waive some out-of-pocket costs as follows:
When Medicare Part A is primary –
Note: Once you have exhausted your Medicare Part A benefits:
When Medicare Part B is primary –
Note: We do not waive benefit limitations, such as the 25-visit limit for home (skilled) nursing visits. In addition, we do not waive any coinsurance or copayments for prescription drugs.
You can find more information about how our Plan coordinates benefits with Medicare in our Medicare and You Guide for Federal Employees available online at www.fepblue.org.
The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.
All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. For example, you must continue to obtain prior approval for some prescription drugs and organ/tissue transplants before we will pay benefits. However, you do not have to precertify inpatient hospital stays when Medicare Part A is primary (see page 21 for exceptions).
Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.
When we are the primary payor, we process the claim first.
When the Original Medicare Plan is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for the covered charges. To find out if you need to do something to file your claims, call us at the customer service phone number on the back of your Service Benefit Plan ID card or visit our website at www.fepblue.org.
We waive some costs if the Original Medicare Plan is your primary payor – We will waive some out-of-pocket costs as follows:
When Medicare Part A is primary –
- Under Standard Option, we will waive our:
- Inpatient hospital per-admission copayments; and
- Inpatient Member and Non-member hospital coinsurance.
- Inpatient hospital per-admission copayments; and
- Under Basic Option, we will waive our:
- Inpatient hospital per-day copayments.
Note: Once you have exhausted your Medicare Part A benefits:
- Under Standard Option, you must then pay any difference between our allowance and the billed amount at Non-member hospitals.
- Under Basic Option, you must then pay the inpatient hospital per-day copayments.
When Medicare Part B is primary –
- Under Standard Option, we will waive our:
- Calendar year deductible;
- Coinsurance and copayments for inpatient and outpatient services and supplies provided by physicians and other covered healthcare professionals; and
- Coinsurance for outpatient facility services.
- Calendar year deductible;
- Under Basic Option, we will waive our:
- Copayments and coinsurance for care received from covered professional and facility providers.
Note: We do not waive benefit limitations, such as the 25-visit limit for home (skilled) nursing visits. In addition, we do not waive any coinsurance or copayments for prescription drugs.
You can find more information about how our Plan coordinates benefits with Medicare in our Medicare and You Guide for Federal Employees available online at www.fepblue.org.