2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 9. Coordinating Benefits With Medicare and Other Coverage
Page 122
Section 9. Coordinating Benefits With Medicare and Other Coverage
Page 122
- Extra care costs – costs of covered services 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 covers extra care costs related to taking part in an approved clinical trial for a covered stem cell transplant such as additional tests that a patient may need as part of the clinical trial protocol, but not as part of the patient’s routine care. For more information about approved clinical trials for covered stem cell transplants, see pages 64-65. Extra care costs related to taking part in any other type of clinical trial are not covered. We encourage you to contact us at the customer service phone number on the back of your ID card to discuss specific services if you participate in a clinical trial.
- 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.
An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (U.S. FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.
When you have Medicare
For more detailed information on “What is Medicare?” and “Should I enroll in Medicare?” please contact Medicare at 1-800-Medicare 800-633-4227, TTY: 711, or at www.medicare.gov.
For more detailed information on “What is Medicare?” and “Should I enroll in Medicare?” please contact Medicare at 1-800-Medicare 800-633-4227, TTY: 711, or at www.medicare.gov.
• 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.
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. For example, you must continue to obtain prior approval for some prescription drugs and organ/tissue transplants before we will pay benefits. However, you do not have to precertify inpatient hospital stays when Medicare Part A is primary (see page 19 for exceptions).
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 the Original Medicare Plan 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 the covered charges. To find out if you need to do something to file your claims, call us at the customer service phone number on the back of your ID card or visit our website at www.fepblue.org.
We waive some costs if the Original Medicare Plan is your primary payor – We will waive some out-of-pocket costs as follows:
When Medicare Part A is primary –
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. For example, you must continue to obtain prior approval for some prescription drugs and organ/tissue transplants before we will pay benefits. However, you do not have to precertify inpatient hospital stays when Medicare Part A is primary (see page 19 for exceptions).
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 the Original Medicare Plan 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 the covered charges. To find out if you need to do something to file your claims, call us at the customer service phone number on the back of your ID card or visit our website at www.fepblue.org.
We waive some costs if the Original Medicare Plan is your primary payor – We will waive some out-of-pocket costs as follows:
When Medicare Part A is primary –
- We will waive our calendar year deductible and coinsurance
- Once you have exhausted your Medicare Part A benefits, you must then pay the coinsurance once the calendar year deductible has been satisfied for the inpatient admission.
Note: Precertification is required.