2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 9. Coordinating Benefits With Medicare and Other Coverage
Page 148
Section 9. Coordinating Benefits With Medicare and Other Coverage
Page 148
Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates whether Medicare or this Plan should be the primary payor for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can administer these requirements correctly. (Having coverage under more than two health plans may change the order of benefits determined on this chart.)
Primary Payor Chart
A. When you - or your covered spouse - are age 65 or over and have Medicare and you...
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above, the primary payor for the individual with Medicare is Medicare.
7) Are enrolled in Part B only, regardless of your employment status, the primary payor for the individual with Medicare is Medicare for Part B services, this Plan for other services.
8) Are a Federal employee receiving Workers' Compensation, the primary payor for the individual with Medicare is this Plan.*
9) Are a Federal employee receiving disability benefits for six months or more, the primary payor for the individual with Medicare is Medicare.
1) Have FEHB coverage on your own as an active employee, the primary payor for the individual with Medicare is this Plan.
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant, the primary payor for the individual with Medicare is Medicare.
3) Have FEHB through your spouse who is an active employee, the primary payor for the individual with Medicare is this Plan.
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above, the primary payor for the individual with Medicare is Medicare.
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant, the primary payor for the individual with Medicare is Medicare.
3) Have FEHB through your spouse who is an active employee, the primary payor for the individual with Medicare is this Plan.
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above, the primary payor for the individual with Medicare is Medicare.
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
- You have FEHB coverage on your own or through your spouse who is also an active employee, the primary payor for the individual with Medicare is this Plan.
- You have FEHB coverage through your spouse who is an annuitant, the primary payor for the individual with Medicare is Medicare.
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above, the primary payor for the individual with Medicare is Medicare.
7) Are enrolled in Part B only, regardless of your employment status, the primary payor for the individual with Medicare is Medicare for Part B services, this Plan for other services.
8) Are a Federal employee receiving Workers' Compensation, the primary payor for the individual with Medicare is this Plan.*
9) Are a Federal employee receiving disability benefits for six months or more, the primary payor for the individual with Medicare is Medicare.
B. When you or a covered family member...
1) Have Medicare solely based on end stage renal disease (ESRD) and...
- It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period), the primary payor for the individual with Medicare is this Plan.
- It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD, the primary payor for the individual with Medicare is Medicare.
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
- This Plan was the primary payor before eligibility due to ESRD (for 30 month coordination period), the primary payor for the individual with Medicare is this Plan.
- Medicare was the primary payor before eligibility due to ESRD, the primary payor for the individual with Medicare is Medicare.
3) Have Temporary Continuation of Coverage (TCC) and...
- Medicare based on age and disability, the primary payor for the individual with Medicare is Medicare.
- Medicare based on ESRD (for the 30 month coordination period), the primary payor for the individual with Medicare is this Plan.
- Medicare based on ESRD (after the 30 month coordination period), the primary payor for the individual with Medicare is Medicare.
C. When either you or a covered family member are eligible for Medicare solely due to disability and you...
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee, the primary payor for the individual with Medicare is this Plan.
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant, the primary payor for the individual with Medicare is Medicare.
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant, the primary payor for the individual with Medicare is Medicare.
D. When you are covered under the FEHB Spouse Equity provision as a former spouse, the primary payor for the individual with Medicare is Medicare.
*Workers' Compensation is primary for claims related to your condition under Workers' Compensation.