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State Members

Coordination of Benefits (COB)

Benefits payable by MCHCP medical plans are subject to coordination of benefits. This prevents overlapping payments for the same service and claim delays. If members are covered under more than one benefit plan, the health plan must be notified.

Under coordination of benefits, one plan is designated as primary and the other is designated as secondary. Claims will be paid by the primary plan first according to its benefits. If applicable, any charges remaining may be paid by the secondary plan.

When MCHCP is secondary, MCHCP benefit payments will not exceed what it would have paid if it were primary. If the primary carrier's payment is more than MCHCP would have paid as primary, MCHCP's payment as secondary payer is zero.

State rules determine which plan is primary. For more information, refer to the Code of State Regulations (22 CSR 10-2.070 Coordination of Benefits).

COB for Medicare and PPO Plans

Remember the following when the MCHCP health plan and Medicare coordinate benefits:

  • When Medicare is the primary payer, providers who accept Medicare assignment will send claims to Medicare first. After Medicare, claims will be sent to the health plan.
  • Members will receive a Medicare Summary Notice and an Explanation of Benefits for each claim. Members are responsible for the Provider May Bill You amount on the Explanation of Benefits.
  • Medicare determines the Medicare Approved amount, which calculates how much Medicare and the health plan will pay.
  • The health plan will not pay for any covered services until the PPO plan deductible is met, unless it is a preventive service covered at 100 percent.
  • Once the deductible is met, members will not pay more than 10 percent of the Medicare Approved amount on covered services.
  • If the PPO plan network out-of-pocket maximum is met, Medicare and the health plan will pay for all covered, network services. Separate PPO network and non-network out-of-pocket maximums exist.
  • Health care expenses apply to both the health plan and Medicare plan deductibles and out-of-pocket maximums. Members do not have to meet two separate deductibles or out-of-pocket maximums.
  • PPO plan copayments do not apply to Medicare members.
  • When using hearing aid benefits, claims will process as network even if the UMR EPIC referral process is not used. Members will not receive the warranty and batteries provided through the EPIC process. MCHCP does not cover replacement hearing aid batteries as a medical plan benefit. When using non-network providers, the hearing aid claim will still pay as network.
List of terms used on Medicare Summary Notices and health plan Explanation of Benefits
Medicare Summary Notice MCHCP Explanation of Benefits Definition
UMR Aetna
Medicare Summary Notice - Amount Charged UMR - Amount Billed Aetna - Billed Amount The amount a provider bills for a service
Medicare Summary Notice - Medicare Approved UMR - Medicare Approved Aetna - Other Carrier Allowed The amount a provider is allowed to charge for a service under Medicare
Medicare Summary Notice - Medicare Paid Provider UMR - Medicare Paid Aetna - Other Carrier Paid The portion Medicare paid of the Medicare Approved amount
Medicare Summary Notice - Not Applicable UMR - Amount Paid Aetna - Plan Paid The portion MCHCP paid of the Medicare Approved amount
Medicare Summary Notice - You May Be Billed UMR - Provider May Bill You Aetna - Member’s Responsibility to Provider (broken down by deductible and coinsurance) The amount a provider may bill you after Medicare or MCHCP pays its portion

 

Example 1

The following example uses the terms found on the Medicare Summary Notice and MCHCP Explanation of Benefits to explain how claims are coordinated with Medicare and MCHCP.

Example #1: Medicare deductible not met/MCHCP deductible not met
Medicare Summary Notice
Amount Charged = $150
Medicare Approved = $100
Medicare Paid Provider = $0
You May Be Billed = $100
MCHCP Explanation of Benefits
Amount Billed = $150
Medicare Approved = $100
Medicare Paid = $0
Amount Paid = $0
Provider May Bill You = $100
You owe the provider $100 and $100 goes toward Medicare and MCHCP plan deductible

 

Example 2

The following example uses the terms found on the Medicare Summary Notice and MCHCP Explanation of Benefits to explain how claims are coordinated with Medicare and MCHCP.

Example #2: Medicare deductible met/MCHCP deductible not met
Medicare Summary Notice
Amount Charged = $150
Medicare Approved = $100
Medicare Paid Provider = $80
You May Be Billed = $20
MCHCP Explanation of Benefits
Amount Billed = $150
Medicare Approved = $100
Medicare Paid = $80
Amount Paid = $0
Provider May Bill You = $20
You owe the provider $20 and $100 goes toward MCHCP plan deductible

 

Example 3

The following example uses the terms found on the Medicare Summary Notice and MCHCP Explanation of Benefits to explain how claims are coordinated with Medicare and MCHCP.

Example #3: Medicare deductible met/MCHCP deductible met
Medicare Summary Notice
Amount Charged = $150
Medicare Approved = $100
Medicare Paid Provider = $80
You May Be Billed = $20
MCHCP Explanation of Benefits
Amount Billed = $150
Medicare Approved = $100
Medicare Paid = $80
Amount Paid = $10*
Provider May Bill You = $10
*MCHCP would have paid 90 percent coinsurance or $90. Medicare paid $80. Subtract what Medicare paid from what MCHCP would have paid.

$90 – $80 = $10   (MCHCP plan pays $10)
You owe the provider $10

 

Example 4

The following example uses the terms found on the Medicare Summary Notice and MCHCP Explanation of Benefits to explain how claims are coordinated with Medicare and MCHCP.

Example #4: Medicare deductible met/MCHCP deductible and out-of-pocket maximum met
Medicare Summary Notice
Amount Charged = $150
Medicare Approved = $100
Medicare Paid Provider = $80
You May Be Billed = $20
MCHCP Explanation of Benefits
Amount Billed = $150
Medicare Approved = $100
Medicare Paid = $80
Amount Paid = $20*
Provider May Bill You = $0
*MCHCP would have paid 100 percent coinsurance or $100. Medicare paid $80. Subtract what Medicare paid from what MCHCP would have paid.

$100 – $80 = $20   (MCHCP plan pays $20)
You owe the provider $0

 

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