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Examples of Coordination of Benefits
Between Medicare & Medical Plan Through MCHCP
(for Medicare Primary Member)
Assumptions: Billed amounts
are not in excess of Medicare allowable amounts, and MCHCP contracted
providers were used.
Example of Several Small
Claims - HMO
Medicare |
Medical
Plan Through MCHCP |
| Billed amount
for 1st office visit to
PCP |
$62.00 |
Billed amount
for 1st office visit to
PCP |
$62.00 |
| Applied to Medicare Part
B deductible. |
62.00 |
Copayment |
25.00 |
| Amount of Medicare Part
B deductible met |
62.00 |
Amount paid by Medicare |
0 |
| Amount paid by Medicare |
0 |
Amount paid by Medical Plan** |
37.00 |
| Member owes prior to MCHCP
coverage |
62.00 |
Member Owes |
$25.00 |
Medicare |
Medical Plan Through MCHCP |
| Billed amount
for 2nd office visit to
PCP |
$62.00 |
Billed amount
for 2nd office visit to
PCP |
62.00 |
| Applied to Medicare Part
B deductible. |
62.00 |
Copayment |
25.00 |
| Amount of Medicare Part B
deductible met |
124.00 |
Amount paid by Medicare |
0 |
| Amount paid by Medicare |
0 |
Amount paid by Medical Plan**
|
37.00 |
| Member owes prior to MCHCP
coverage |
62.00 |
Member Owes |
$25.00 |
Medicare |
Medical
Plan Through MCHCP |
| Billed amount
for 3rd office visit to
PCP |
$62.00 |
Billed amount
for 3rd office visit to PCP |
62.00 |
| Applied to Medicare Part
B deductible. |
7.00 |
Copayment |
25.00 |
| Amount of Medicare Part
B deductible met |
131.00 |
Amount paid by Medicare |
44.00 |
Amount paid by Medicare
(80% of $55)* |
44.00 |
Amount paid by Medical Plan** |
18.00 |
| Member owes prior to MCHCP
coverage |
$18.00 |
Member Owes |
$0 |
Example of One Large Claim
- HMO
Medicare |
Medical
Plan Through MCHCP |
| Billed amount
for 1st hospitalization |
$1,250.00 |
Billed amount
for 1st hospitalization |
$1,250.00 |
| Applied to Medicare Part
A deductible** |
992.00 |
Copayment |
300.00 |
| Amount of Medicare Part
A deductible met |
992.00 |
Amount paid by Medicare |
258.00 |
| Amount paid by Medicare |
258.00 |
Amount paid by Medical Plan |
950.00 |
| Member owes prior to MCHCP
coverage |
$992.00 |
Member Owes |
$42 |
*Once the deductible is met, Medicare pays
80% of the remaining Medicare allowable amount left.
**Maximum amount paid by MCHCP = Total Bill
- Copayment. Payments are based on Medicare allowable amount.
Medicare Part B deductible for 2005 is $131.
Medicare Part A deductible for 2005 is $92.
Examples use 2007 Medicare deductible amounts.
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