Plans Other than Medicare
If you or any covered dependents are covered by more than one group medical or dental plan, reimbursements are coordinated between the plans so that benefits are not duplicated. Note: This provision does not apply to the Symetra Benefits Plan.
When you are covered by more than one plan, the plan that pays benefits first is called the primary plan. The primary plan pays its benefits without considering what the other plan may pay.
The other plan (secondary plan) may pay additional benefits depending on its coordination of benefits (COB) provisions. When the ACS plan is secondary, your reimbursement is adjusted so that the total reimbursement you receive from both plans is not more than the amount that would have been paid if you were only covered by the ACS plan. You must apply for benefits under the primary plan before the claims administrator will consider a claim under this plan.
The following rules determine which plan will pay first:
• If one of the plans has no COB provision, that plan is always primary.
• When both plans have a COB provision:
○ The plan covering the person as an employee is the primary plan. (The ACS plan is primary for all covered ACS employees.)
○ If you and your spouse both cover your children and you are not separated or divorced, the plan of the parent whose birthday (month and day) occurs first in the calendar year is primary.
• The plan covering the person as an active employee or the dependent of an active employee pays benefits before a plan that covers the person as a laid off or retired employee or his/her dependents. (If the other plan does not include this or a similar rule, it will not apply.)
• The plan covering the person as an active employee or the dependent of an active employee pays benefits before the plan that covers the person as a COBRA participant. If the plan covering the person as an active employee has a pre-existing condition exclusion, expenses for the pre-existing condition will be paid first by the COBRA plan.
If you and your spouse are legally separated or divorced and you both cover your children, the following rules apply:
• If a court or administrative order makes one parent financially responsible for the child’s health care coverage, that parent’s plan is primary.
• If the court does not assign financial responsibility for the child’s health care through a Qualified Medical Child Support Order (QMCSO), the plan of the parent with legal custody is primary. If joint custody, the plan of the parent whose birthday (month and day) occurs first in the calendar year is primary. If both parents have the same birthday, the plan that has covered the child longer is the primary plan.
• If the parent with legal custody remarries, the order of payment is:
○ The plan of the parent with custody is primary;
○ The plan of the stepparent is secondary; and
○ The plan of the parent without custody is third.
If none of these rules apply, the plan that has covered the person longer is the primary plan.
Other Plans
The term “other group medical plan” in this section includes any of the following:
• Group or group-type plans, including franchise or blanket benefit plans;
• Group practice and other group prepayment plans;
• Other plans required or provided by law (other than Medicaid); and
• No-fault motor vehicle coverage.
Other COB Provisions
Right to Exchange Information
In order to coordinate benefit payments, the claims administrator needs certain information. The claims administrator has the right to obtain the information necessary to apply the rules stated previously, or to give information to any other organization or individual for the same purpose.
The claims administrator is not required to obtain your consent of or to notify the individuals about whom such information is sought.
The covered person must give the claims administrator the information it asks for about other plans. If the covered person cannot furnish all the information the claims administrator needs, the claims administrator has the right to get this information from any source. If this information is not provided by the covered person or the requested source, your claim for benefits may be denied.
Payments Made
A payment made under another plan may include an amount that should have been paid under this plan. If it does, this plan may pay that amount to the organization that made the payment.
That amount will then be treated as though it was a benefit paid under this plan. We will not have to pay that amount again.
The term “payment made” includes providing benefits in the form of services, in which case “payment made” means reasonable cash value of the benefits provided in the form of services.
Right of Recovery
If the amount of payments the plan makes is more than it should have paid under this COB provision, the plan may recover the excess from one or more of the individuals the plan paid or for whom the plan paid; or any other individual or organization that may be responsible for the benefits or services provided for you. The amount of the payments made includes the reasonable cash value of any benefit provided in the form of services.
Medicare and Government Plans
Benefits provided through a ACS Medical Plan are not intended to supplement any coverage provided by Medicare. Nevertheless, in some circumstances individuals who are eligible for or are enrolled in Medicare may also be enrolled under this plan.
Medicare
When an individual who is covered under an ACS Medical Plan becomes eligible for Medicare, this plan pays its benefits in accordance with the Medicare Secondary Payer requirements of federal law. If ACS is subject to the Medicare Secondary Payer requirements, this plan will pay primary.
An Important Note about Medicare Enrollment Requirements
When this plan pays benefits first, without regard to Medicare, and you want Medicare to pay after this plan, you must enroll for Medicare Parts A and B.
If you do not enroll for Medicare when first eligible, you must enroll during the special enrollment period which applies to you when you stop being eligible under this plan.
When Medicare would pay benefits first, benefits available under Medicare are deducted from the amounts payable under this plan, regardless of whether the individual has actually enrolled for Medicare. If Medicare would be your primary payer, you should enroll for both Parts A and B of Medicare when you are first eligible; otherwise, the expenses may not be covered by this plan or Medicare.
When this Plan Pays Primary to Medicare
This plan pays primary to Medicare for individuals enrolled in Medicare if eligibility for Medicare is due to the individual being:
• Age 65, and the employee has “current employment status” with ACS as defined by federal law and determined by ACS.
• Disabled, and the employee has “current employment status” with ACS as defined by federal law and determined by ACS.
This plan will also be primary if eligibility for Medicare is due to end stage renal disease (ESRD) under the conditions of and for the time periods specified by federal law, generally no longer than 30 months.
When Medicare Pays Primary to this Plan
Medicare pays primary to this plan (as outlined below) for individuals enrolled in Medicare if eligibility for Medicare is due to:
• Disability and the employee does not have “current employment status” with the employer as defined by federal law and determined by the employer; or,
• End stage renal disease (ESRD), but only after the conditions and/or time periods specified in federal law cause Medicare to become primary.
How this Plan Pays when Medicare Is Primary
If Medicare pays benefits first, this plan pays benefits as described below. This method of payment only applies to individuals eligible for Medicare. It does not apply to any covered individual unless that individual becomes eligible under Medicare and Medicare is the primary payer.
• The amount of charges for covered expenses under this plan is determined first. However, the amount of covered expenses is based on the amount of charges allowed under Medicare rules instead of the reasonable charges as defined by the plan.
• Then, the amount payable under Medicare for the same expenses is subtracted from the amount the plan would have paid if the ACS plan were your only coverage. This plan pays the difference between the two amounts.
• The amount payable under Medicare which is subtracted from this plan’s benefits is determined as the amount that would have been payable under Medicare when Medicare is primary even if the individual:
○ Is not enrolled for Medicare—Medicare benefits are determined as if the person were covered under Medicare Parts A and B.
○ Is enrolled in a Medicare+Choice (Medicare Part C) plan and receives non-covered out-of-network services because the individual did not follow all rules of that plan—Medicare benefits are determined as if the services were covered under Medicare Parts A and B.
○ Receives services from a provider who has elected to opt out of Medicare—Medicare benefits are determined as if the services were covered under Medicare Parts A and B, and the provider had agreed to limit charges to the amount of charges allowed under Medicare rules.
○ Receives services in a Veterans Administration facility or other facility of the federal government—Medicare benefits are determined as if the services were provided by a non-governmental facility and covered under Medicare.
○ Is enrolled under a plan with a Medicare Medical Savings Account—Medicare benefits are determined as if the person were covered under Medicare Parts A and B.
An Important Note about ACS’ Prescription Drug Benefits and Medicare Part D
Medicare participants are eligible to receive prescription drug benefits through Medicare, provided they enroll in—and pay the extra premium for—Medicare Part D. However, it’s important to understand that the prescription drug benefits provided through the ACS PPO Plan and the Consumer Choice Plan are deemed “creditable” and thus a Medicare-eligible individual who is also covered under one of these plans can choose not to enroll in Medicare Part D and continue to receive prescription drug benefits through his or her ACS plan. Furthermore, such individual can generally enroll in Medicare Part D at a later date without penalty since he or she was covered under a plan that provided “creditable coverage,” as long as there is not a break in coverage of more than 63 days.
The Limited Benefit Plans (Aetna Affordable Health Plan, CIGNA Starbridge Choice Plan, and Symetra Medical Plan) do not provide “creditable coverage.” If you are enrolled in an HMO, information about these plans and creditable coverage is included in the Notice.
ACS distributes notices of creditable coverage in accordance with Medicare regulations.
Government Plans (other than Medicare and Medicaid)
If you or a dependent are also covered under a government plan, this plan does not cover any services or supplies to the extent that those services or supplies, or benefits for them, are available to the individual under the government plan.
This provision does not apply to any government plan, which by law requires this plan to pay primary.
A government plan is any plan, program or coverage—other than Medicare or Medicaid—established under the laws or regulations of any government, or in which any government participates other than as an employer.
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Questions about your employee benefits or other Human Resources issues? Contact the Workplace Solutions Center at (888) 471-2271.