Medicare Estimation is a process for determining the secondary payment when Medicare Part B is primary, and the
\nmember has not enrolled in Medicare Part B. Medicare Estimation reduces the payment by the amount the primary Medicare Part B would have paid if the eligible member was enrolled. This amount is not covered by the fully insured plan. Remind your impacted members to consider enrolling in Medicare Part B.<\/p>\n
Applicability<\/strong> Medicare. Medicare Estimation does not<\/strong> apply in these scenarios: The reduction is permissible under NY rule 11 NYCRR 52.23(l).<\/p>\n The process is described in the member\u2019s certificate of coverage. For your reference, the New York plan exclusions state: Our process applies to Medicare-eligible members who have Medicare Part A, but not Medicare Part B, and Medicare is primary. Medicare Estimation is a process for determining the secondary payment when Medicare Part B is primary, and the member has not enrolled in Medicare Part B. Medicare Estimation reduces the payment by the amount the primary Medicare Part B would have paid if the eligible member was enrolled. This amount is not covered by the […]<\/p>\n","protected":false},"author":5,"featured_media":8161,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"mc4wp_mailchimp_campaign":[],"footnotes":""},"categories":[411],"tags":[3667,221,2223],"class_list":["post-8157","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicare","tag-medicare-coordination","tag-medicare-coordination-of-benefits","tag-medicare-estimation"],"yoast_head":"\n
\nMedicare Estimation applies in any of the following scenarios:
\n\u2022 Member has Part A and no Part B, and Medicare is primary.
\n\u2022 Member has both Parts A and B (primary), but provider does not bill or participate in Medicare or has specifically opted out of Medicare.
\n\u2022 Member has Part B only (primary), but provider does not bill or participate in Medicare or has specifically opted out of<\/p>\n
\n\u2022 Member has Part B, and provider is participating with Medicare. If the member has Part B, we pay secondary based on the actual amount Medicare paid.
\n\u2022 Medicare (any part) is the member\u2019s secondary payer.
\n\u2022 Member is not eligible for Medicare.<\/p>\n
\n\u2022 Medicare or other governmental programs: \u201cWe do not Cover services if benefits are provided for such services under the federal Medicare program or other governmental program (except Medicaid). When You are eligible for Medicare, we will reduce our benefits by the amount Medicare would have paid for the Covered Services. Except as otherwise required by law, this reduction is made even if You fail to enroll in Medicare or You do not pay Your Medicare Premium. Benefits for Covered Services will not be reduced if We are required by federal law to pay first or if You are not eligible for premium-free Medicare Part A.\u201d<\/p>\n
\n\u2022 Medicare is primary in these scenarios:
\no Medicare due to age, and group size is 19 or less.
\no Medicare due to disability, and group size is 99 or less.
\no Medicare due to end-stage renal disease (ESRD), and Medicare is primary depending on what stage of dialysis treatment
\nmember is in.
\no Medicare primary (regardless of reason or group size) and a member not actively working (COBRA, state continuation, retiree).<\/p>\n","protected":false},"excerpt":{"rendered":"