SSMC Employee Health Benefit Plan
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C. Medicare Effect on the Order of Benefit Determination
Please refer to "Your Medicare Handbook" which can be obtained at your local Social Security Office, for
details on current Medicare Secondary Payer (MSP) rules. Also, see Section VI - Medicare Integration with
Plan Benefits. Generally, if Medicare is considered primary coverage, the order of benefit determination could
be changed as follows:
1. For individuals eligible for Medicare due to age (65 or over) or due to disability who are covered under a
plan as a person with current employment status, or a dependent of a person with current employment
status, the following order of benefit determination applies:
a. All active plans (employees with current employment status and their Eligible Dependents) pay first.
b. Medicare pays second.
c. Retired plans, or employees without current employment status plans, pay last.
2. For individuals eligible for Medicare solely due to ESRD, the order of benefit determination is as follows:
a. Medicare pays last for the first 30 months following the month of first eligible ESRD treatment. Usual
order of benefit determination would apply for other group plans.
b. Medicare pays first after the first 30 months. Other plans would be secondary following the order of
benefit determination.
D. COB Effect on Plan Benefits
When this Plan is secondary, benefits will be reduced so that the total benefits paid or provided by all plans are
not more than 100% of the allowable expenses Incurred during a claim determination period. When benefits
are so reduced, each benefit is reduced in proportion and applied against any applicable benefit limit of the
Plan.
When this Plan is secondary, payment could be reduced if the benefits available for the Covered Expenses
under this Plan (without this COB provisions) and the benefits payable by all other involved plans are more
than 100%. Then, the benefits of This Plan will be reduced so that they, and the benefits payable under the
other plan(s), do not total more than the total allowable expenses Incurred during a claim determination period.
When the benefits of This Plan are so reduced, each benefit is reduced in proportion. It is then charged against
any applicable benefit limit of This Plan.
When a Covered Person fails to file a claim with the primary payer, benefits for the primary plan will be
estimated. If a person is eligible for Medicare primary coverage according to Medicare secondary payer rules
and is not enrolled in Medicare Part A and/or Part B or in Part C, then Medicare benefits will be estimated. The
estimated other plan or Medicare payments will be used to determine the benefit reduction under this COB
provision.
E. Right to Receive and Release Needed Information
Certain facts are needed to apply these COB rules and to determine benefits payable under this plan and other
plans. The Claims Administrator may get the facts it needs from, or give them to, any other organization or
person for the purpose of applying these rules and determining benefits payable under this plan and other plans
covering the person for whom claim is made. The Claims Administrator need not tell, nor get the consent of,
any person to do this. Each person claiming benefits under the Plan must give the Claims Administrator any
facts required to pay the claim.
