PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II Chapter 1: Getting started as a member • Changes in any other health insurance coverage you have (such as from your employer, your spouse’s employer, workers’ compensation, or Medicaid) • If you have any liability claims, such as claims from an automobile accident • If you have been admitted to a nursing home • If you receive care in an out-of-area or out-of-network hospital or emergency room • If your designated responsible party (such as a caregiver) changes • If you are participating in a clinical research study If any of this information changes, please let us know by calling Customer Service (phone numbers are printed on the back cover of this booklet). Read over the information we send you about any other insurance coverage you have Medicare requires that we collect information from you about any other medical or drug insurance coverage that you have. Th at’s because we must coordinate any other coverage you have with your benefi ts under our plan. (For more information about how our coverage works when you have other insurance, see Section 7 in this chapter.) Once each year, we will send you a letter that lists any other medical or drug insurance coverage that we know about. Please read over this information carefully. If it is correct, you don’t need to do anything. If the information is incorrect, or if you have other coverage that is not listed, please call Customer Service (phone numbers are printed on the back cover of this booklet). SECTION 6 WE PROTECT THE PRIVACY OF YOUR PERSONAL HEALTH INFORMATION Section 6.1 We make sure that your health information is protected Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws. For more information about how we protect your personal health information, please go to Chapter 8, Section 1.4 of this booklet. SECTION 7 HOW OTHER INSURANCE WORKS WITH OUR PLAN Section 7.1 Which plan pays fi rst when you have other insurance? When you have other insurance (like employer group health coverage), there are rules set by Medicare that decide whether our plan or your other insurance pays fi rst. Th e insurance that pays fi rst is called the “primary payer” and pays up to the limits of its coverage. Th e one that pays second, called the “secondary payer,” only pays if there are costs left uncovered by the primary coverage. Th e secondary payer may not pay all of the uncovered costs. 11
12 Th ese rules apply for employer or union group health plan coverage: • If you have retiree coverage, Medicare pays fi rst. 2013 Evidence Evidence of Coverage Coverage for PPO II Chapter 1: Getting started as a member • If your group health plan coverage is based on your or a family member’s current employment, who pays fi rst depends on your age, the size of the employer, and whether you have Medicare based on age, disability, or End-stage Renal Disease (ESRD): � If you’re under 65 and disabled and you or your family member is still working, your plan pays fi rst if the employer has 100 or more employees or at least one employer in a multiple employer plan has more than 100 employees. � If you’re over 65 and you or your spouse is still working, the plan pays fi rst if the employer has 20 or more employees or at least one employer in a multiple employer plan has more than 20 employees. • If you have Medicare because of ESRD, your group health plan will pay fi rst for the fi rst 30 months after you become eligible for Medicare. Th ese types of coverage usually pay fi rst for services related to each type: • No-fault insurance (including automobile insurance) • Liability (including automobile insurance) • Black lung benefi ts • Workers’ compensation Medicaid and TRICARE never pay fi rst for Medicare-covered services. Th ey only pay after Medicare, employer group health plans, and/or Medigap have paid. If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about who pays fi rst, or you need to update your other insurance information, call Customer Service (phone numbers are printed on the back cover of this booklet). You may need to give your plan member ID number to your other insurers (once you have confi rmed their identity) so your bills are paid correctly and on time.
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55 Water Street, New York, New York
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PPO II - EmblemHealth

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