SSMC Employee Health Benefit Plan
65
SECTION VI- MEDICARE INTEGRATION WITH PLAN BENEFITS
If Medicare is primary, Plan benefits will be reduced by Medicare benefits. Medicare primary plan status is
determined according to Medicare Secondary Payer (MSP) rules established by federal regulations. Revisions
or changes in these MSP rules will automatically apply. If you or your Dependents are eligible for Medicare
primary benefits, claims should be submitted to Medicare first. Medicare explanation of benefits should be
attached to your claims for this Plan. Refer to "Your Medicare Handbook" for information and details on
Medicare coverage. This handbook can be obtained at your local Social Security Office.
You or your Dependents are responsible for Medicare enrollment. If you or your Dependent does not hear from
the Social Security Office at least three months before a 65th birthday or within 12 months after starting Social
Security disability benefits, you or your Dependent should call your local Social Security office for assistance.
Persons who have end stage kidney disease should contact the Social Security Office for eligibility and
enrollment details. If this Plan is primary coverage for your health care, Medicare regulations allow you to
delay Medicare enrollment until this Plan becomes secondary according to Medicare Secondary Payer rules.
Your local Social Security Office can provide details on enrollment requirements and penalties for late
enrollment.
This Medicare integration provision applies to all persons eligible for primary Medicare coverage even if the
person is not actually enrolled in Medicare. If not enrolled for primary Medicare coverage, Medicare benefits
will be estimated.
A. Medicare Secondary Payer (MSP) Current Rules
Currently, the following general MSP rules apply for persons eligible for Medicare:
1. Persons Eligible for Medicare due to age (65 and over) or Due to Disability.
a. Medicare is secondary to the plan that covers this person as a person with current employment status,
or the dependent of a person with current employment status.
b. Medicare is primary to the plan that covers this person as a retiree or a person without current
employment status, or the dependent of a retiree or a person without current employment status.
2. Persons Eligible for Medicare due to End Stage Renal Disease (ESRD). Once Medicare eligibility is
established due to ESRD, the eligible person is entitled to full Medicare coverage. Medicare coverage is
not limited to ESRD expenses.
a. Medicare Eligibility Solely Due to ESRD. Medicare is secondary for the first 30 months following
the month of the ESRD eligibility date for persons eligible solely due to ESRD. (Before August 1,
1997, Medicare was secondary for the first 18 months.)
b. Medicare ESRD Dual Eligibility. ESRD dual eligibility means a person who is eligible for Medicare
due to age and ESRD or due to disability and ESRD.
1) If a group plan is appropriately paying secondary to Medicare according to MSP rules for
eligibility due to age or disability and ESRD entitlement then becomes effective, Medicare remains
the primary payer. The 30-month ESRD period does not apply.
2) If the group plan is paying primary according to MSP rules for eligibility due to age or disability
and then ESRD entitlement becomes effectiv e, Medicare remains secondary until after 30-month
ESRD period. At the end of the 30-month ESRD period, the group plan becomes primary or
secondary payer based on the MSP rules for age and disability.
3) If a group plan is paying primary to Medicare according to MSP rules for ESRD, and then the
person becomes eligible due to age or disability, Medicare remains secondary until the end of the
