SSMC Employee Health Benefit Plan
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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.
B. Effects of Medicare on Plan Benefits
If Medicare is primary for you or your Dependent, the benefits of the Plan will be integrated as follows:
1. Medicare Payment Integration. Medicare payment for health expenses covered by this Plan will reduce
the Allowable Fees (Network or Out-of-Network) for those expenses. The balance after this reduction will
be paid up to the usual Plan benefits. The combination of the Medicare payment and the Plan payment will
not exceed the usual Plan benefits for any Covered Services.
2. Not enrolled in Medicare. This integration will apply to persons eligible for Medicare whether or not
actually enrolled in Medicare. If Medicare is primary for an eligible person who is not enrolled in Medicare
Part A and Part B or in Part C, the Medicare benefit will be estimated and used to reduce Allowable Fees.
This could result in significant reduction or denial of the Plan benefits.
3. Medicare Private Contract Options. This integration will apply to persons eligible for Medicare primary
benefits if Medicare benefits are not paid due to a Medicare Private Contract Option with Physicians and
certain other practitioners. (When a Medicare beneficiary agrees to the terms of a Private Contract with
certain Providers, Medicare will not pay. The patient is responsible for the entire char ge. The Provider may
bill more than the charges allowed by Medicare.) Under this Plan, if a private contract is used, Medicare
benefits will be estimated. Part A services will be estimated according to Medicare payment rules. Part B
or similar services under Part C will be estimated based on 80% of Usual, Customary and Reasonable
Charges for Covered Services or Supplies without regard to Medicare deductibles and other coinsurance
limits. The estimated Medicare benefits will be used to coordinate benefits. This could result in significant
reduction or denial of the Plan benefits.
4. Medicare HMO or Participating Provider Programs. This integration will not apply when Medicare
and a Medicare sponsored HMO denies coverage due to its enrolled beneficiaries failure to abide by the
HMO or Participating Provider Program requirements. This Plan will not cover the expenses for those
Services or Supplies and Plan benefits will not be paid.
C. Allowable Fees
Allowable Fees for Medicare integration only will be based on the following:
1. If the Provider accepts Medicare assignment of benefits, the Allowable Fees will be the same fees allowed
by Medicare.
2. If the Provider does not accept Medicare assignment, the Allowable Fees will be based on the Usual,
Customary and Reasonable Charges for out-of-Network Providers, the Network allowance for Network
Providers or the charges determined by Medicare limiting charge regulations, whichever is the lower
charge.
3. If the Provider provides services under a Medicare Private Contract Option, Allowable Fees will be based
on the Usual, Customary and Reasonable or the Participating Provider Network allowance, if applicable,
for services Covered by this Plan.
According to Medicare regulations, a beneficiary cannot be billed the difference between the Medicare allowed
amounts and the Provider's charges when that Provider accepts Medicare assignment. If a Provider does not
accept assignment, the Provider cannot bill a beneficiary for charges that are more than the limiting charge
established by Medicare for that service by that Provider. However, if services are provided under the
Medicare Private Contract Option, the Provider's charges can exceed the Medicare allowable fees.
