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.
Claims process when you have the Original Medicare Plan—You probably will 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 Original Medicare 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 covered charges. To find out if you need to do something to file a claim, call us at 877-814-NALC (6252) or see our website at www.nalchbp.org.
High Option: We waive some costs if the Original Medicare Plan is your primary payor. We will waive some out-of-pocket costs as follows:
- If you have Medicare Part A as primary payor, we waive:
- The copayment for a hospital admission.
- The coinsurance for a hospital admission.
- The deductible for inpatient care in a treatment facility.
- If you have Medicare Part B as primary payor, we waive:
- The copayments for office or outpatient visits.
- The copayments for allergy injections.
- The coinsurance for services billed by physicians, other healthcare professionals, and facilities.
- All calendar year deductibles.
When Medicare is the primary payor and is not covering a service or supply that is covered by the Plan, we will review the Medicare Summary Notice or Medicare Remittance Advice Statement to see if the charge is a contractual obligation (CO) or if it is the patient’s responsibility (PR). When the service or supply is the patient’s responsibility, we will pay either the charge or our Plan allowance, whichever is less, at 100%.
If we believe Medicare may have incorrectly denied a service or supply, we will ask the provider or facility to refile to Medicare.
Note: If you have Medicare Part B as primary payor, we will not waive the copayments for mail order drugs, or the coinsurance for retail prescription drugs.
Please review the following examples which illustrate your cost share if you are enrolled in Medicare Part B. If you purchase Medicare Part B, and your provider participates in Medicare, we will waive some costs because Medicare will be the primary payor.
Deductible High Option: You pay without Medicare: PPO: $300 per person/$600 per family High Option: You pay without Medicare: Non-PPO: $300 per person/$600 per family High Option: You pay with Medicare Part B: $0 High Option: You pay with Medicare Part B: $0
Catastrophic Protection Out-of-pocket maximum High Option: You pay without Medicare: PPO: $3,500 per person/ $7,000 per family High Option: You pay without Medicare: Non-PPO: $5,000 per person/$10,000 per family PPO/Non-PPO combined High Option: You pay with Medicare Part B: PPO: $0 High Option: You pay with Medicare Part B: Non-PPO: $0
Part B premium reimbursement offered High Option: You pay without Medicare: PPO: N/A High Option: You pay without Medicare: Non-PPO: N/A High Option: You pay with Medicare Part B: PPO: N/A High Option: You pay with Medicare Part B: Non-PPO: N/A
Primary care provider High Option: You pay without Medicare: PPO: $25 copay High Option: You pay without Medicare: Non-PPO: 35% after deductible High Option: You pay with Medicare Part B: PPO: $0 High Option: You pay with Medicare Part B: Non-PPO: $0
Specialist High Option: You pay without Medicare: PPO: $25 copay High Option: You pay without Medicare: Non-PPO: 35% after deductible High Option: You pay with Medicare Part B: PPO: $0 High Option: You pay with Medicare Part B: PPO: $0
Inpatient hospital High Option: You pay without Medicare: PPO: $350 per admission High Option: You pay without Medicare: Non-PPO: $450 per admission and 35% High Option: You pay with Medicare Part B: PPO: $350 per admission High Option: You pay with Medicare Part B: Non-PPO: $450 per admission and 35%
Outpatient hospital High Option: You pay without Medicare: PPO: 15% after deductible or $350 observation High Option: You pay without Medicare: Non-PPO: 35% after deductible High Option: You pay with Medicare Part B: PPO: $0 High Option: You pay with Medicare Part B: Non-PPO: $0
Rewards offered High Option: You pay without Medicare: In-Network: N/A High Option: You pay without Medicare: Out-of-Network: N/A High Option: You pay with Medicare Part B: In-Network: N/A High Option: You pay with Medicare Part B: Out-of-Network: N/A
*When we are the secondary payor, we usually pay what is left after the primary plan, up to our regular benefit for each claim. We will not pay more than our allowance.
Consumer Driven Health Plan: When Original Medicare (either Medicare Part A or Medicare Part B) is the primary payor, we will not waive any out-of-pocket costs.
When we are the secondary payor, we limit benefits to the difference between our liability (as the primary carrier) and the Medicare payment. When our liability is equal to, or less than, the Medicare payment, you will receive no benefit.
Note: We do not waive our deductible, copayments or coinsurance for prescription drugs or for services and supplies that Medicare does not cover. Also, we do not waive benefit limitations, such as the 12-visit limit for chiropractic services or the 50-visit limit for physical, occupational or speech therapy.
You can find more information about how our plan coordinates benefits with Medicare in Medicare and You, and Medicare Benefits at a Glance at www.nalchbp.org.
Please review the following examples which illustrate your cost share if you are enrolled in Medicare Part B. If you purchase Medicare Part B, you are still responsible for applicable deductibles, and coinsurance for charges billed by In-Network or Out-of-Network providers.
Deductible CDHP: You pay without Medicare: In-Network:$2,000 Self only/$4,000 Self Plus One/$4,000 Self and Family CDHP: You pay without Medicare: Out-of-Network: $4,000 Self only/$8,000 Self Plus One/$8,000 Self and Family CDHP: You pay with Medicare Part B: In-Network: $2,000 Self only/$4,000 Self Plus One/$4,000 Self and Family CDHP: You pay with Medicare Part B: Out-of-Network: $4,000 Self only/$8,000 Self Plus One/$8,000 Self and Family
Catastrophic Protection Out-of-pocket maximum CDHP: You pay without Medicare: In-Network: $6,600 per person/$12,000 per family CDHP: You pay without Medicare: Out-of-Network: $12,000 per person/$24,000 per family CDHP: You pay with Medicare Part B: In Network: $6,600 per person/$12,000 per family CDHP: You pay with Medicare Part B: Out-of-Network: $12,000 per person/$24,000 per family
Part B premium reimbursement offered CDHP: You pay without Medicare: In-Network: N/A CDHP: You pay without Medicare: Out-of-Network: N/A CDHP: You pay with Medicare Part B: In-Network: N/A CDHP: You pay with Medicare Part B: Out-of-Network: N/A
Primary care provider CDHP: You pay without Medicare: In-Network: 20% of the Plan allowance CDHP: You pay without Medicare: Out-of-Network: 50% of the Plan allowance and the difference, if any, between our allowance and the billed amount CDHP: You pay with Medicare Part B: In-Network: The difference between our liability (as the primary carrier) and the benefits that Medicare would pay under Medicare Part B, regardless of whether Medicare pays. When our liability is equal to, or less than, the Medicare payment, you will pay all charges CDHP: You pay with Medicare Part B: Out-of-Network: The difference between our liability (as the primary carrier) and the benefits that Medicare would pay under Medicare Part B, regardless of whether Medicare pays. When our liability is equal to, or less than, the Medicare payment, you will pay all charges.
Specialist CDHP: You pay without Medicare: In-Network: 20% of the Plan allowance CDHP: You pay without Medicare: Out-of-Network: 50% of the Plan allowance and the difference, if any, between our allowance and the billed amount CDHP: You pay with Medicare Part B: In-Network: The difference between our liability (as the primary carrier) and the benefits that Medicare would pay under Medicare Part B, regardless of whether Medicare pays. When our liability is equal to, or less than, the Medicare payment, you will pay all charges CDHP: You pay with Medicare Part B: Out-of-Network: The difference between our liability (as the primary carrier) and the benefits that Medicare would pay under Medicare Part B, regardless of whether Medicare pays. When our liability is equal to, or less than, the Medicare payment, you will pay all charges
Inpatient hospital CDHP: You pay without Medicare: In-Network: 20% of the Plan allowance CDHP: You pay without Medicare: Out-of-Network: 50% of the Plan allowance and the difference, if any, between our allowance and the billed amount CDHP: You pay with Medicare Part B: In-Network: The difference between our liability (as the primary carrier) and the benefits that Medicare would pay under Medicare Part A, regardless of whether Medicare pays. When our liability is equal to, or less than, the Medicare payment, you will pay all charges CDHP: You pay with Medicare Part B: Out-of-Network: The difference between our liability (as the primary carrier) and the benefits that Medicare would pay under Medicare Part A, regardless of whether Medicare pays. When our liability is equal to, or less than, the Medicare payment, you will pay all charges
Outpatient hospital CDHP: You pay without Medicare: In-Network: 20% of the Plan allowance CDHP: You pay without Medicare: Out-of-Network: 50% of the Plan allowance and the difference, if any, between our allowance and the billed amount CDHP: You pay with Medicare Part B: In-Network: The difference between our liability (as the primary carrier) and the benefits that Medicare would pay under Medicare Part B, regardless of whether Medicare pays. When our liability is equal to, or less than, the Medicare payment, you will pay all charges CDHP: You pay with Medicare Part B: Out-of-Network: The difference between our liability (as the primary carrier) and the benefits that Medicare would pay under Medicare Part B, regardless of whether Medicare pays. When our liability is equal to, or less than, the Medicare payment, you will pay all charges
Rewards offered CDHP: You pay without Medicare: In-Network: N/A CDHP: You pay without Medicare: Out-of-Network: N/A CDHP: You pay with Medicare Part B: In-Network: N/A CDHP: You pay with Medicare Part B: Out-of-Network: N/A
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