High Option Plan

Medicare Benefits

When you have Medicare as the primary payer and the NALC Health Benefit Plan High Option, charges for services and supplies covered by Medicare are paid in full between Medicare and the Plan. When Medicare applies the calendar year deductible and coinsurance to services payable by Part A or Part B, the Plan pays 100% of the balance resulting in no out-of-pocket costs to you!

When Medicare is primary payer and covers the charges you are not required to:

If you are approaching age 65 or are age 65 and retired, you need to understand the importance of having total medical and prescription drug coverage. You may be in good health today, but that could change unexpectedly.

Medicare Part A (Hospital Insurance) is generally cost-free.  For those who do not meet the work credit requirements, you may be able to buy Part A (and Part B) by paying a monthly premium. Part A benefits help to pay for inpatient hospital care, inpatient skilled nursing facility care, home health and hospice care. There are deductibles and coinsurance which apply to these expenses that are your responsibility, but when you are enrolled in the NALC Health Benefit Plan High Option, we pay these for you! To make it even easier for you, once the facility or provider files the claim to Medicare and Medicare considers the claim, that information is securely transmitted to us. No paperwork on your part!

Medicare Part B (Medical Insurance) Once you approach age 65, you will receive notice from the Centers for Medicare and Medicaid Services (CMS) that you are eligible to enroll in Medicare Part B. If you are receiving Social Security benefits, once you enroll, the premium is deducted from your monthly Social Security benefits. Medicare Part B benefits help you pay for doctor charges, diagnostic services, ambulance charges, surgeries, medical equipment and supplies, and covered services not covered or payable under Medicare Part A. When you are enrolled in the NALC Health Benefit Plan High Option and Medicare Part B, your Medicare Part B plan will pay benefits as the primary payor (pays first). Your Medicare Part B claims are transmitted electronically to the NALC Health Benefit Plan High Option where we will pay the Medicare Part B deductible and coinsurance on covered services. You will not have any out-of-pocket expense since we supplement Medicare’s payment up to 100% of the covered charge.

Medicare Part C (Medicare Advantage Plans) are Medicare health plan options that are part of the

Medicare program. If you decide to join one of the many Medicare Advantage plans, you generally must receive all of your Medicare covered health care through that Plan. Medicare Advantage plans can also include prescription drug coverage. Included in the Medicare Advantage plans are Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), private fee-for-service plans, and Medicare Special Needs plans. In some cases, there are extra benefits and lower copayments than in the original Medicare plan. However, you may be required to receive treatments or referrals only from providers that belong to that Medicare Advantage Plan in order to receive benefits.

Medicare Part D (Prescription Drug Plan) If you are enrolled in Medicare, you are eligible to enroll in a Medicare Prescription Drug Plan. There are many plans from which to choose, and each has an additional premium. When you are enrolled in a Medicare Part D Plan and Medicare Part D pays first, the NALC Health Benefit Plan High Option will waive your retail fill limit and retail day’s supply limitations. We will coordinate benefits as the secondary payor and pay the balance after Medicare’s drug payment or our prescription drug benefit; whichever is the lesser amount.

You can get more information about Medicare plan choices by calling 800-633-4227 or at www.medicare.gov.

Always rely on the Plan’s official approved brochure (RI 71-009) for complete detailed information of the Plan’s benefits when Medicare is not paying for the service or supply.

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