AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

employment with the Employer. If coverage under this Plan is not on account of current employment
status with the Employer, and you are eligible for Medicare solely by reason of disability, Medicare is
primary and this Plan is secondary. Note that in this latter case – where this Plan is secondary – this Plan
will deem you or your Dependent, to be enrolled in Medicare Parts A, B and D even if you or your
Dependent have not so enrolled.
Medicare eligibility by reason of end stage renal disease
This Plan is primary and Medicare is secondary if you are eligible for Medicare solely on the basis of End
Stage Renal Disease (“ESRD”), are not eligible for Medicare by reason of age or disability, and your
coverage under this Plan is on account of your (or someone else’s) current employment with the
Employer. However, this Plan is primary only during the first 30 months of such eligibility for Medicare
benefits. This 30-month period generally begins on the earlier of:
• The first day of the fourth month during which a regular course of renal dialysis starts; or
• If you receive a kidney transplant, the first day of the month during which you become eligible for
Medicare.
If you are eligible for Medicare solely on the basis of ESRD, you must be covered by Parts A and B to get
the full benefits available under Medicare to cover ESRD treatment. You may also enroll in Part D if you
need coverage for certain prescribed drugs that may not be covered under Part B. If you enroll in
Medicare Part A and defer enrolling in Part B during the 30-month coordination period, you will be
charged a premium penalty by Medicare when you enroll in Part B if you delay enrolling by 12 or more
months. In addition, this provision does not apply if at the start of your eligibility for this Plan you were
already eligible for Medicare benefits and this Plan’s benefits were payable on a secondary basis.
In order to assist your Employer and the Claims Administrator in complying with Medicare Secondary
Payer (“MSP”) laws, it is very important that you promptly and accurately complete any requests for
information from the Claim Administrator and/or your Employer regarding the Medicare eligibility of you,
your spouse and covered Dependent children. In addition, if you, your spouse or covered Dependent
child becomes eligible for Medicare, or has Medicare eligibility terminated or changed, please contact
your Employer or the Claim Administrator promptly to ensure that your claims are processed in
accordance with applicable MSP laws.
UPDATING COB INFORMATION — YOUR RESPONSIBILITY
It is important to keep your COB records updated. If there are any changes in coverage information for
you or your Dependents, notify your Employer and the Claims Administrator immediately. Please help the
Plan Administrator and Claims Administrator serve you better by responding to requests for COB
information quickly. The Plan will request updated COB information at least yearly. If COB information
such as cancellation of other coverage, switching other coverage carriers or changes in custody or court
ordered coverage for Dependent children is not updated, claims could be rejected inappropriately or
incorrect information may be sent to your health care providers.
If the information you provided on your latest COB letter of inquiry is more than one year old and a claim
is submitted under the Plan for you, your spouse or your Dependent children, the claim will be temporarily
held. The Claims Administrator will send you a new letter of inquiry requesting information about other
carriers. When you respond, the Claims Administrator will update your record. The claim will then be
processed according to the appropriate COB rules.
Important: If you do not respond to the Claims Administrator’s letter of inquiry within 45 days of its
receipt, the claim will be denied due to lack of current COB information. In addition, all other claims for
you, your spouse and your Dependents will be denied until the COB letter of inquiry is returned.
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