Medicare Benefits: Coordination and Claims

Benefits payable from MCHCP plans are subject to coordination of benefits. MCHCP plans work with the various group plans to make sure each pays what it should up to the total amount of medical allowable expenses. Through coordination of benefits, the cost of health care is managed by avoiding two payments for the same charge. (This provision does not apply to individual policies you may own.)

Under coordination of benefits, one plan is designated as “primary” (which means it pays first) and the other is designated as “secondary” (which means it pays up to any covered expenses that are not paid by the primary plan). In some instances you may also be eligible for benefits under a third plan. When you are retired and are or become eligible for Medicare, Medicare is your primary payor except for end stage renal disease.

Benefits of the plans are the same for active and retired members. However, in order to obtain maximum benefits, remember to follow your medical plan’s guidelines. Also, refer to Using Your Medical Plan for more information. As the secondary payor, claims payments are based on benefits provided by MCHCP, not Medicare eligible benefits.

If you are retired and eligible for Medicare, take note of the following statements. (These also apply to your spouse.)

• To receive maximum benefits, you must be enrolled in both Medicare Parts A and B.
• If you are not enrolled in Medicare Parts A and B, you are responsible for the amount Medicare would have paid.
• Medicare is primary; your MCHCP health insurance plan is secondary.
• You are not subject to pre-certification for hospital admissions or outpatient surgical procedures. Any of your covered dependents who are not Medicare eligible are subject to the pre-certification process.