The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 In order to enroll in the UnitedHealthcare or Medica Plan option, your dependent must be enrolled in Medicare Parts A and B to receive benefits. If your dependent is not enrolled in Medicare Parts A and B, they will not be eligible to continue coverage in the Program. If you and your covered dependents are enrolled in the Early Retiree Medical or Comprehensive option, and your dependent turns age 65 or becomes Medicare eligible before age 65, you and your dependents will remain in the Early Retiree Medical or Comprehensive option. Your coverage cost also will not change when a covered dependent turns age 65 or becomes Medicare eligible before age 65. However, for that dependent, Medicare Parts A and B will be considered the primary insurer, effective the first of the month in which the dependent turns age 65 (or the first of the prior month if the dependent’s birthday is on the first of the month). The Program will assume that your dependent has enrolled in Medicare Parts A and B and Blue Cross and Blue Shield of Minnesota will process your claims as if you had Medicare Part A and Part B, whether or not that is actually the case. If your dependent doesn’t have Medicare Part A and Part B, your dependent must pay the portion that Medicare would have paid. The Program only pays benefits when the benefit amount payable under the Program exceeds the Medicare payment. Preadmission Notification and Prior Authorization If your covered dependent is age 65 or older and enrolled in the Early Retiree Medical option or the Comprehensive option, certain requirements, such as “preadmission notification” and “prior authorization” do not apply, because Medicare is primary except for certain organ transplant services and bariatric surgery. See the Transplants section or the Bariatric Surgery section in this SPD. Your Benefit Option Integration With Medicare Currently, the Medicare Program consists of Part A for inpatient services, and Part B for physician services, outpatient services, and supplies and equipment. If your covered dependent is enrolled in the Early Retiree Medical option or the Comprehensive option and is eligible for Medicare, the Program assumes that your dependent is enrolled in Medicare Parts A and B, whether or not that is actually the case. For Parts A and B, Medicare is considered their primary insurer. Because the U.S. Bank Retiree Health Care Program (the Program) integrates coverage with Medicare Part A and Part B, your dependents must be enrolled in both programs to receive your full benefits. (For example: If you don’t enroll in Medicare Part B, BCBS will process your claims as if you had Medicare Part B. You must pay the portion of the claim that Medicare would have paid under Part B.) The Early Retiree Medical and Comprehensive options work in conjunction with Medicare Parts A and B, and pays benefits when the benefit amount payable under the Program (the amount that the option would pay if it were your primary insurer) exceeds the Medicare payment. Here is how Medicare Parts A and B and the Early Retiree Medical and Comprehensive options work together: 1. Medicare pays its benefit after you satisfy the applicable Medicare deductible(s). 2. The Program calculates its normal benefit based on Medicare’s approved amount. If the Program’s normal benefit (after your plan deductible) is greater than the Medicare payment, 58
Retiree Health Care SPD Effective January 1, 2012 the Program pays the difference between the Medicare payment and the Program’s normal benefit. 3. You pay the remaining amount. When Medicare provides the same level of benefits for a service as the Program would pay (if it were primary), the Program does not pay any benefit for that service. This means that the Program may not pay any benefit for many medical services. If Medicare pays less than the Program, the Program will pay the difference. If there is no Medicare coverage for a service covered by the Program, the Program pays the benefit for that service. Example of Integration With Medicare (enrolled in Early Retiree Medical option-Family coverage level)* Total Charge $1,300 Medicare approved amount $1,000 This is just an example. Actual Medicare approved amounts are based on Medicare fee schedules. What the Program would have $0 75% after $3000 combined medical/pharmacy paid if primary deductible (based on Medicare’s approved amount). What Medicare pays $720 80% of approved amount after $100 deductible. What the Program pays $0 Difference between what Medicare pays and what the Program would pay if it were primary. What you pay* $280* ($1,000-$720=$280)* *The example provided assumes the provider has accepted assignment with Medicare. If the provider does not accept assignment with Medicare, you may be billed up to the total charge. Also, the example assumes you have enrolled in Medicare Parts A and B if you are eligible to do so. If that was not the case, you would also be responsible for the amount noted in the row “What Medicare Pays” ($720). Claiming Health Care Benefits with Medicare If your dependent is enrolled in the Early Retiree Medical or Comprehensive option, some providers will file claims with Medicare and then BCBS. If your dependent’s provider does not, your dependent will need to file their claims with Medicare first. When Medicare has processed their claim, they will receive an Explanation of Benefits. Send this form, along with the claim form from BCBS, to the address on the back of the ID card. Your dependent will need to contact BCBS for claim forms. To be eligible for payment, your dependent’s claims must be received by BCBS within 12 months from the date of service. 59
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The eligibility and enrollment rules for the U

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