Claims for Medicare Eligible Retirees

HMO Claims

• The HMO provider files all claims with Medicare.
• You do not have to meet Medicare Part A or B deductibles before your medical plan pays claims.
• You are responsible for paying copayments and coinsurance amounts, the same as if you were an active employee, unless the payments from Medicare and your MCHCP medical plan exceed the amount of Medicare allowable charges. To further explain, you do not owe a copayment to the provider if:
  • Your Medicare deductible has been satisfied, AND
  • The payments made to your provider by Medicare and your MCHCP medical plan met Medicare’s allowable fee.

If the amount paid by Medicare and your MCHCP medical plan are less than the Medicare allowable fee, you can be charged up to the amount of your copayment.

Refer to the Examples of Coordination of Benefits Between Medicare and Medical Plan Through MCHCP (for Medicare Primary Member). Section 3045.2 of the Medicare Carrier Manual indicates that a provider who accepts Medicare assignments is prohibited from collecting amounts in excess of Medicare’s reasonable charge (Medicare’s allowable fee). If you receive care from a non-network provider and the claim is for non-eligible Medicare charges, neither Medicare nor your HMO plan will pay toward the charges.

Copay Plan through Coventry Health Care (network claims)

• Network providers file claims for you.

Copay Plan through Coventry Health Care (non-network claims)

• You may be responsible for filing the claim with Medicare.
• When you receive the Explanation of Medicare Benefits (EOMB), you may have to file the claim with Coventry Health Care including a copy of the EOMB.