Medicare Secondary Payer Provisions. Individuals are eligible for Medicare and can be covered under it because of age, disability or end stage renal disease (ESRD). Individuals are also eligible for Medicare even when not covered under it if they refused it, dropped it or did not make a proper request for it. When you are eligible for Medicare, AvMed coordinates your benefits under this plan with the benefits Medicare pays. If you are eligible but not covered under Medicare, we may coordinate your benefits under this Plan with the benefits Medicare would pay had you enrolled. If you become Medicare eligible while covered under the Plan, you should visit xxx.xxxxxxxx.xxx or contact your local Social Security office to learn about your eligibility, coverage options, enrollment periods and necessary steps to follow to ensure that you have adequate coverage.
a. If you are eligible for Medicare due to age, have group health coverage based on you or your spouse’s current employment and the employer has 20 or more employees, the group health plan is primary and Medicare is secondary.
b. If you are eligible for Medicare due to ESRD and have group health coverage based on you or your spouse’s current employment, the group health plan is primary for the first 30 months beginning with the earlier of:
i. the month in which you became covered under Medicare Part A ESRD benefits; or
ii. the first month in which you would have been covered under Medicare Part A ESRD benefits if a timely application had been made.
iii. After 30 months, Medicare is primary and the group health plan is secondary.
c. If you are eligible for Medicare due to a disability other than ESRD, have group health coverage based on you or a family member’s current employment and the employer has:
i. 100 or more employees: the group health plan is primary and Medicare is secondary;
ii. less than 100 employees: Medicare is primary and the group health plan is secondary.
d. If you are eligible for Medicare due to age and have retiree coverage, Medicare is primary and the group health plan (retiree coverage) is secondary.
e. If you become covered under Medicare and are still eligible and covered under a group health plan, the employer may not offer, subsidize, procure or provide a Medicare supplement policy to you; nor may an employer persuade you to decline or terminate your coverage under the plan and elect Medicare as the primary payer.
