2019 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 9. Coordinating Benefits With Medicare and Other Coverage
Page 129
 
When you are age 65 or over and do not have Medicare

Under the FEHB law, we must limit our payments for inpatient hospital care and physician care to those payments you would be entitled to if you had Medicare. Your physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had Medicare. You and the FEHB benefit from these payment limits. Outpatient hospital care and non-physician-based care are not covered by this law; regular Plan benefits apply. The following chart has more information about the limits.
 
If you:
  • are age 65 or over; and
  • do not have Medicare Part A, Part B, or both; and
  • have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and
  • are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)
 
Then, for your inpatient hospital care:
  • The law requires us to base our payment on an amount – the “equivalent Medicare amount” – set by Medicare’s rules for what Medicare would pay, not on the actual charge.
  • You are responsible for your deductible, coinsurance, or copayments under this Plan.
  • You are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you.
  • The law prohibits a hospital from collecting more than the equivalent Medicare amount.
 
And, for your physician care, the law requires us to base our payment and your applicable coinsurance or copayment on:
  • an amount set by Medicare and called the “Medicare-approved amount,” or
  • the actual charge if it is lower than the Medicare-approved amount.
 
If your physician: Participates with Medicare or accepts Medicare assignment for the claim and is a member of our PPO network
Then you are responsible for: your deductibles, coinsurance, and copayments.

If your physician: Participates with Medicare and is not in our Preferred network
Then you are responsible for: all charges.

If your physician: Does not participate with Medicare and is in our Preferred network
Then you are responsible for: your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare-approved amount.

Note: In many cases, your payment will be less because of our Preferred agreements. Contact your Local Plan for information about what your specific Preferred provider can collect from you.

If your physician: Does not participate with Medicare and is not a member in our Preferred network
Then you are responsible for: all charges.

If your physician: Opts-out of Medicare via private contract and is in our Preferred network
Then you are responsible for: your deductibles, coinsurance, copayments, and any balance your physician charges.