Procedures to be Followed by the Secondary Plan to Calculate Benefits. In order to determine which procedure to follow it is necessary to consider: the basis on which the Primary Plan and the Secondary Plan pay benefits; and whether the provider who provides or arranges the services and supplies is in the network of either the Primary Plan or the Secondary Plan. Benefits may be based on the Allowed Charge (AC), or some similar term. This means that the provider bills a charge and the [Member] may be held liable for the full amount of the billed charge. In this section, a Plan that bases benefits on an Allowed Charge is called an “AC Plan.” Benefits may be based on a contractual fee schedule, sometimes called a negotiated fee schedule, or some similar term. This means that although a provider, called a network provider, bills a charge, the [Member] may be held liable only for an amount up to the negotiated fee. In this section, a Plan that bases benefits on a negotiated fee schedule is called a “Fee Schedule Plan.” Fee Schedule Plans may require that [Members] use network providers. Examples of such plans are Health Maintenance Organization plans (HMO) and Exclusive Provider organization plans (EPO). If the [Member] uses the services of a non-network provider, the plan will be treated as an AC Plan even though the plan under which he or she is covered allows for a fee schedule. Examples of such plans are Preferred provider organization plans (PPO) and Point of Service plans (POS). Payment to the provider may be based on a “capitation”. This means that the HMO, EPO or other plans pays the provider a fixed amount per [Member]. The [Member] is liable only for the applicable deductible, coinsurance or copayment. If the [Member] uses the services of a non-network provider, the HMO or other plans will only pay benefits in the event of emergency care or urgent care. In this section, a Plan that pays providers based upon capitation is called a “Capitation Plan.” In the rules below, “provider” refers to the provider who provides or arranges the services or supplies and “HMO” refers to a health maintenance organization plan and “EPO” refers to Exclusive Provider Organization. Primary Plan is an AC Plan and Secondary Plan is an AC Plan The Secondary Plan shall pay the lesser of: the difference between the amount of the billed charges and the amount paid by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. When the benefits of the Secondary Plan are reduced as a result of this calculation, each benefit shall be reduced in proportion, and the amount paid shall be charged against any applicable benefit limit of the plan. Primary Plan is Fee Schedule Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in both the Primary Plan and the Secondary Plan, the Allowable Expense shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. The total amount the provider receives from the Primary plan, the Secondary plan and the [Member] shall not exceed the fee schedule of the Primary Plan. In no event shall the [Member] be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. Primary Plan is an AC Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in the Secondary Plan, the Secondary Plan shall pay the lesser of: the difference between the amount of the billed charges for the Allowable Expenses and the amount paid by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. The [Member] shall only be liable for the copayment, deductible or coinsurance under the Secondary Plan if the [Member] has no liability for copayment, deductible or coinsurance under the Primary Plan and the total payments by both the primary and Secondary Plans are less than the provider’s billed charges. In no event shall the [Member] be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is an AC Plan If the provider is a network provider in the Primary Plan, the Allowable Expense considered by the Secondary Plan shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is an AC Plan or Fee Schedule Plan If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the [Member] receives from a non-network provider is not considered as urgent care or emergency care, the Secondary Plan shall pay benefits as if it were the Primary Plan. Primary Plan is Capitation Plan and Secondary Plan is Fee Schedule Plan or an AC Plan If the [Member] receives services or supplies from a provider who is in the network of both the Primary Plan and the Secondary Plan, the Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. Primary Plan is Capitation Plan or Fee Schedule Plan or an AC Plan and Secondary Plan is Capitation Plan If the [Member] receives services or supplies from a provider who is in the network of the Secondary Plan, the Secondary Plan shall be liable to pay the capitation to the provider and shall not be liable to pay the deductible, coinsurance or copayment imposed by the Primary Plan. The [Member] shall not be liable to pay any deductible, coinsurance or copayments of either the Primary Plan or the Secondary Plan. Primary Plan is an HMO or EPO and Secondary Plan is an HMO or EPO If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the [Member] receives from a non-network provider is not considered as urgent care or emergency care, but the provider is in the network of the Secondary Plan, the Secondary Plan shall pay benefits as if it were the Primary Plan. Except that the Primary Plan shall pay out-of-Network services, if any, authorized by the Primary Plan.
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Samples: www.nj.gov, www.nj.gov, www.nj.gov
Procedures to be Followed by the Secondary Plan to Calculate Benefits. In order to determine which procedure to follow it is necessary to consider: the basis on which the Primary Plan and the Secondary Plan pay benefits; and whether the provider who provides or arranges the services and supplies is in the network of either the Primary Plan or the Secondary Plan. Benefits may be based on the Allowed Charge (AC), or some similar term. This means that the provider bills a charge and the [Member] may be held liable for the full amount of the billed charge. In this section, a Plan that bases benefits on an Allowed Charge is called an “AC Plan.” Benefits may be based on a contractual fee schedule, sometimes called a negotiated fee schedule, or some similar term. This means that although a provider, called a network provider, bills a charge, the [Member] may be held liable only for an amount up to the negotiated fee. In this section, a Plan that bases benefits on a negotiated fee schedule is called a “Fee Schedule Plan.” Fee Schedule Plans may require that [Members] use network providers. Examples of such plans are Health Maintenance Organization plans (HMO) and Exclusive Provider organization plans (EPO). If the [Member] uses the services of a non-network provider, the plan will be treated as an AC Plan even though the plan under which he or she is covered allows for a fee schedule. Examples of such plans are Preferred provider organization plans (PPO) and Point of Service plans (POS). Payment to the provider may be based on a “capitation”. This means that the HMO, EPO or other plans pays the provider a fixed amount per [Member]. The [Member] is liable only for the applicable deductible, coinsurance or copayment. If the [Member] uses the services of a non-network provider, the HMO or other plans will only pay benefits in the event of emergency care or urgent care. In this section, a Plan that pays providers based upon capitation is called a “Capitation Plan.” In the rules below, “provider” refers to the provider who provides or arranges the services or supplies and “HMO” refers to a health maintenance organization plan and “EPO” refers to Exclusive Provider Organization. Primary Plan is an AC Plan and Secondary Plan is an AC Plan The Secondary Plan shall pay the lesser of: the difference between the amount of the billed charges and the amount paid by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. When the benefits of the Secondary Plan are reduced as a result of this calculation, each benefit shall be reduced in proportion, and the amount paid shall be charged against any applicable benefit limit of the plan. Primary Plan is Fee Schedule Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in both the Primary Plan and the Secondary Plan, the Allowable Expense shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. The total amount the provider receives from the Primary plan, the Secondary plan and the [Member] shall not exceed the fee schedule of the Primary Plan. In no event shall the [Member] be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. Primary Plan is an AC Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in the Secondary Plan, the Secondary Plan shall pay the lesser of: the difference between the amount of the billed charges for the Allowable Expenses and the amount paid by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. The [Member] shall only be liable for the copayment, deductible or coinsurance under the Secondary Plan if the [Member] has no liability for copayment, deductible or coinsurance under the Primary Plan and the total payments by both the primary and Secondary Plans are less than the provider’s billed charges. In no event shall the [Member] be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is an AC Plan If the provider is a network provider in the Primary Plan, the Allowable Expense considered by the Secondary Plan shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is an AC Plan or Fee Schedule Plan If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the [Member] receives from a non-network provider is not considered as urgent care or emergency care, the Secondary Plan shall pay benefits as if it were the Primary Plan. Primary Plan is Capitation Plan and Secondary Plan is Fee Schedule Plan or an AC Plan If the [Member] receives services or supplies from a provider who is in the network of both the Primary Plan and the Secondary Plan, the Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. Primary Plan is Capitation Plan or Fee Schedule Plan or an AC Plan and Secondary Plan is Capitation Plan If the [Member] receives services or supplies from a provider who is in the network of the Secondary Plan, the Secondary Plan shall be liable to pay the capitation to the provider and shall not be liable to pay the deductible, coinsurance or copayment imposed by the Primary Plan. The [Member] shall not be liable to pay any deductible, coinsurance or copayments of either the Primary Plan or the Secondary Plan. Primary Plan is an HMO or EPO and Secondary Plan is an HMO or EPO If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the [Member] receives from a non-network provider is not considered as urgent care or emergency care, but the provider is in the network of the Secondary Plan, the Secondary Plan shall pay benefits as if it were the Primary Plan. Except that the Primary Plan shall pay out-of-Network services, if any, authorized by the Primary Plan.. Procedures to be Followed when a Person is Eligible for Medicare Part B but Not Enrolled This [Contract] reduces its benefits as described below for Members who are eligible for Medicare if Medicare is the Primary Plan. See the Medicare as Secondary Payor section to determine whether Medicare is the Primary plan. Medicare benefits are determined as if the allowed amount that would have been payable under Medicare Part B was actually paid by Medicare Part B, even if the Member is eligible but not enrolled in Medicare Part B.
Appears in 1 contract
Samples: www.state.nj.us
