Section 9. Coordinating benefits with other coverage

When you have other health coverage You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays health care expenses without regard to fault. This is called double coverage.

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners guidelines.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance or up to our regular benefit, whichever is less. We will not pay more than our allowance. The combined payments from both plans may not equal the entire amount billed by the provider. In certain circumstances, when there is no adverse effect on you (that is, you do not pay any more), we may also take advantage of any provider discount arrangements your primary plan may have and pay only the difference between the primary plans payment and the amount the provider has agreed to accept as payment in full from the primary plan.

Please see Section 4, Your costs for covered services, for more information about how we pay claims.
What is Medicare? Medicare is a health insurance program for:
  • People 65 years of age or older;

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  • Some people with disabilities under 65 years of age; and

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  • People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).
Medicare has four parts:
  • Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (If you were a Federal employee at any time both before and during January 1983, you will receive credit for your Federal employment before January 1983.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) for more information.

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  • Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check.

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  • Part C (Medicare Advantage). You can enroll in a Medicare Advantage plan to get your Medicare benefits. We do not offer a Medicare Advantage plan. Please review the information on coordinating benefits with Medicare Advantage plans on page 68.

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  • Part D (Medicare prescription drug coverage). There is a monthly premium for Part D coverage. If you have limited savings and a low income, you may be eligible for Medicare's Low-Income Benefits. For people with limited income and resources, extra help in paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA). For more information about this extra help, visit SSA online at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Before enrolling in Medicare Part D, please review the important disclosure notice from us about the FEHB prescription drug coverage and Medicare. The notice is on the first inside page of this brochure. The notice will give you guidance on enrolling in Medicare Part D.
•   Should I enroll in Medicare? The decision to enroll in Medicare is yours. We encourage you to apply for Medicare benefits 3 months before you turn age 65. Its easy. Just call the Social Security Administration toll-free number 1-800-772-12131213, (TTY 1-800-325-0778) to set up an appointment to apply. If you do not apply for one or more Parts of Medicare, you can still be covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal employees and annuitants are entitled to Medicare Part A at age 65 without cost. When you don't have to pay premiums for Medicare Part A, it makes good sense to obtain the coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social Security Administration can provide you with premium and benefit information. Review the information and decide if it makes sense for you to buy the Medicare Part B coverage.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare Advantage is the term used to describe the various private health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on whether you are in the Original Medicare Plan or a private Medicare Advantage plan.

(Please refer to page 17 for information about how we provide benefits when you are age 65 or older and do not have Medicare.)
•   The Original Medicare Plan (Part A or Part B) 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.

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 will probably 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 your claim, call us at 1-800/638-6589 or 301/984-1440 (for TDD, use 301/984-4155) or see our Web site at www.SambaPlans.com.

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 are enrolled in Medicare Part B, we will waive the deductibles, copayments and coinsurances for:
    • Surgery and anesthesia services

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    • Mental health and substance abuse benefits

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    • Medical services and supplies provided by physicians and other health care professionals

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    • Outpatient services by a hospital and other facilities and ambulance services

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    • Dental benefits

    Note: The prescription drug copayment is not waived.

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  • If you are enrolled in Medicare Part A, we will waive the following:
    • the per confinement copayment for inpatient hospital confinements

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    • the coinsurance for inpatient hospital benefits

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    In cases where we cover a service that is not covered by Medicare, we are the primary payor. In these cases, we do not waive any out-of-pocket costs.
•   Tell us about your Medicare coverage You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.
•   Private Contract with your physician A physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after Original Medicares payment. You may be responsible for paying the difference between the billed amount and the amount we paid.
•   Medicare Advantage (Part C) If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plans Medicare Advantage plan: You may enroll in another plans Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plans network and/or service area, but we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage Plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plans service area.
•   Medicare prescription drug coverage (Part D) If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan.

Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates whether Medicare or this Plan should be the primary payor for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can administer these requirements correctly. (Having coverage under more than two health plans may change the order of benefits determined on this chart.)
Primary payor Chart
A. When you -- or your covered spouse -- are age 65 or over and have Medicare and you... The primary payor for the individual with Medicare is...
Medicare This Plan
1) Have FEHB coverage on your own as an active employee
  X
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant
X  
3) Have FEHB through your spouse who is an active employee
  X
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above
X  
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
•   You have FEHB coverage on your own or through your spouse who is also an active employee
  X
  •   You have FEHB coverage through your spouse who is an annuitant
X  
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above
X  
7) Are enrolled in Part B only, regardless of your employment status
X for Part B
services
X for other
services
8) Are a Federal employee receiving Workers Compensation disability benefits for six months or more
X  *  
B. When you or a covered family member...
1) Have Medicare solely based on end stage renal disease (ESRD) and...
•   It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)
  X
  •   It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD
X  
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
•   This Plan was the primary payor before eligibility due to ESRD (for 30 month coordination period)
  X
  •   Medicare was the primary payor before eligibility due to ESRD
X  
3) Have Temporary Continuation of Coverage (TCC) and...
•   Medicare based on age and disability
X  
  •   Medicare based on ESRD (for the 30 month coordination period)
  X
  •   Medicare based on ESRD (after the 30 month coordination period)
X  
   C. When either you or a covered family member are eligible for Medicare solely due to disability and you...
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee
  X
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant
X  
   D. When you are covered under the FEHB Spouse Equity provision as a former spouse X  

*Workers Compensation is primary for claims related to your condition under Workers Compensation.
TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.
Workers Compensation We do not cover services that:
  • You need because of a workplace-related illness or injury that the Office of Workers Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or


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  • OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

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Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.
Medicaid When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these State programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the State program.
When other Government agencies are responsible for your care We do not cover services and supplies when a local, State, or Federal government agency directly or indirectly pays for them.
When others are responsible for injuries If you or any covered member of your family suffers injuries in an accident or become ill because of another persons act or omission, and you later receive compensation for the injuries or illness from that person or your own or other insurance, you are required to reimburse us out of that compensation for any benefits we paid on your behalf or, if applicable, to you, your heirs, estate, administrators, successors, or assignees. This is known as our right of reimbursement, and is also sometimes referred to as subrogation.

You will have this obligation to reimburse us even if the compensation you receive is not sufficient to compensate you fully for all of the damages which resulted from the injuries or illness. In other words, we are entitled to be reimbursed for those benefit payments even if you are not made whole for all of our damages by the compensation you receive. Our right of reimbursement is also not subject to reduction for attorneys fees under the common fund doctrine without our written consent. In short, we are entitled to be reimbursed for 100% of the benefits we pay on account of the injuries or illness unless we agree in writing to accept a lesser amount.

We enforce this right of reimbursement by asserting a priority lien against any and all compensation you receive by court order or out-of-court settlement, without regard to how it is characterized, for example as pain and suffering. You must cooperate with our enforcement of our right of reimbursement by:
  • telling us promptly whenever you have filed a claim for compensation resulting from an accidental injury or illness;

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  • accepting our lien for the full amount of the benefits we have paid;

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  • agreeing to assign any proceeds from third party claims or your own insurance to us if we ask you to do so;

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  • keeping us advised of the claims status;

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  • advising us of any settlement or court order;

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  • and promptly reimbursing us out of any recovery received to the full extent of our right of reimbursement.
You must also sign a Reimbursement Agreement for this purpose when asked to do so. We will not pay benefits until this Agreement is signed. Our right to full reimbursement applies even to benefits we paid before learning of a potential recovery, and before asking you to sign a Reimbursement Agreement; it also applies to any benefits payable on covered expenses incurred but not submitted for payment to us or processed by us before the date of a settlement or court order. Failure to cooperate with these obligations may result in the temporary suspension of your benefits and/or offsetting of future benefits.

If you would like more information about the subrogation process and how it works, please call our Third Party Recovery Services unit at 202-683-9140.
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) Some FEHB Plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on BENEFEDS.com, you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.
Clinical Trials If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:
  • Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy. These costs are covered by this Plan.
  • Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care. This Plan does not cover these costs.
  • Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials, this Plan does not cover these costs.

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