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What is the UPREHS Health Care Prepayment Plan?
The UPREHS Medicare Secondary Plan
Use your UPREHS Health Insurance Card and your red, white, and blue Medicare Card
Help us keep your membership record up to date
UPREHS participating or in-network providers
Nonparticipating or out-of-network providers
Does the UPREHS HCPP have a geographic service area?
To get a list of UPREHS participating providers
Find UPREHS participating providers when you travel
Access to your personal information
Primary Care Provider (PCP)
What to do if you have a medical emergency or urgent need for care
UPREHS does not require referral for getting care from specialists
What if your doctor stops participating with UPREHS?
Can your benefits change during the year?
What is the UPREHS Health Care Prepayment Plan?
UPREHS is contracted as a Health Care Prepayment Plan (HCPP) with the Centers for Medicare and Medicaid Services (CMS), the Federal agency that administers Medicare. This contract authorizes UPREHS to pay your Original Medicare Part B claims to participating providers for office visits and office services, consultations, hospital visits, and surgical procedures. When UPREHS HCPP receives a participating physician’s claim for your services, payments for Original Medicare Part B benefits and your UPREHS Medicare Secondary Plan benefits are made in one check directly to the physician, which eliminates billing Railroad Medicare and you.
The UPREHS HCPP contract with CMS renews annually on January 1 of each year. Either CMS or UPREHS may terminate the contract by providing advance notice to each other and to you. If the contract ends, your UPREHS Medicare Secondary Plan benefits will continue in force, and we will explain what your options are at that time if it should ever occur.
UPREHS Medicare members are still receiving Original Medicare Part A and B benefits. UPREHS HCPP members continue get their Medicare benefits through Original Medicare Part A and B whether or not the provider is participating with UPREHS. UPREHS HCPP does not change Original Medicare Part B benefits; congressional law creates and defines those benefits. The UPREHS Board of Trustees determines only the premium amounts and the benefits that are paid secondary to Original Medicare under the UPREHS Medicare Secondary Plan (MSP).
You may choose to get care out-of-network anywhere and at any time using your Original Medicare benefits. UPREHS HCPP cannot pay the Original Medicare Part B payments for UPREHS nonparticipating providers even if an emergency or urgent care. Railroad Medicare processes the Medicare claims for your out-of-network claims and certain in-network Part B benefits. Your UPREHS Medicare Secondary Plan benefit payment is reduced to 40% for out-of-network services except for emergency or urgent care for the first 24 hours.
Participating physicians can send claims to UPREHS HCPP or Railroad Medicare to receive the Original Medicare Part B payment. If their claims are sent to Railroad Medicare, UPREHS cannot automatically pay your Medicare Secondary Plan benefits; either you or the physician must send the Medicare Summary Notice (MSN) to UPREHS to receive the secondary payment.
UPREHS HCPP does make the Original Medicare Part B payment for the following UPREHS participating physician services:
• Office visits and related office services
• Consultations
• Hospital visits
• Surgical procedures
UPREHS HCPP does not make the Original Medicare Part B payment for any of the items and/or services listed below. Regardless of the participation status of the provider, claims for those services are sent to Railroad Medicare and the MSN is sent to UPREHS for Medicare Secondary Plan payments (when a covered benefit).
• Alcohol and substance abuse treatments
• Ambulance services
• Ambulatory Surgical Facility (ASF) and other facility services
• Anesthesia services
• Chiropractic services
• Dialysis treatment and supplies
• DME, orthotics and prosthetics
• Hospice services
• Home nursing services
• In and outpatient hospital services and other facility services
• Mammography
• Independent clinical laboratory and pathology
• IV home infusion therapy
• Mental health treatments
• Nutritional supplements
• Optometry
• Oral cancer, immunotherapy, and intravenous immune globulin drugs
• Organ transplant services
• Oxygen and associated equipment and supplies
• Physical, speech and occupational therapy
• Podiatry services
• Psychiatry
• Preventive health care services
The UPREHS Medicare Secondary Plan
TIME LIMIT FOR FILING A CLAIM FOR UPREHS MSP BENEFITS
Claims for Medicare secondary benefits under the UPREHS MSP must be filed with UPREHS within one-year of the time the claim was first processed by any Medicare claims processor.
The UPREHS Medicare Secondary Plan (MSP) makes payment for covered benefits after Original Medicare Part A or B or the UPREHS HCPP has paid the primary Medicare payment for allowed services. UPREHS MSP pays the Medicare Part A and B annual deductible amounts and coinsurance for allowed charges for covered benefits. You may be partly or totally financially responsible for charges that Medicare did not pay from nonparticipating providers. The UPREHS MSP reduces payment to 40% of the Medicare coinsurance and annual deductible amounts for covered benefits from UPREHS nonparticipating providers. A UPREHS nonparticipating provider is a physician, hospital, or other health care provider who has not signed a UPREHS participation agreement. UPREHS does not know if these providers participate with Medicare or not. All Medicare members who elect coverage under the UPREHS MSP are also automatically enrolled in the UPREHS Medicare HCPP. Members must be entitled to Original Medicare Part A and enrolled in Part B to elect coverage under the UPREHS MSP and HCPP.
There are some benefits that are not covered by Original Medicare Part A and B that are covered by your UPREHS MSP (see UPREHS Medicare Plan Benefits Chart in Section 4). There are also some benefits that are covered by Original Medicare Part A and B that are not covered benefits by your UPREHS MSP (see UPREHS Medicare Plan Benefits Chart in Section 4).
If Medicare does not allow for payment for an item or service, there is usually no UPREHS MSP payment to be made (see UPREHS Medicare Plan Benefits Chart in Section 4). Your UPREHS MSP does not make payment for any service or item that is already paid in full by Medicare, or an amount higher than the Medicare allowed amount for any covered benefit. Benefit payments are secondary to Original Medicare Part A and B payments with very few exceptions.
The amount UPREHS MSP pays for covered benefits depends on whether your services are obtained from UPREHS participating providers or nonparticipating providers, whether the out-of-network services were emergency or urgent care and in some cases limits may apply to covered benefits. However, UPREHS out-of-network reductions do not apply to the Original Medicare payment amount. (see UPREHS Medicare Plan Benefits Chart in Section 4 and Benefit Exclusions in Section 5.)
Use your Plan membership card instead of your red, white, and blue Medicare card
You must present both your red, white and blue Medicare Card and your combined UPREHS Health Insurance and Prescription Drug ID Card when you receive hospital, physician, and other health care services. Your UPREHS Health Insurance ID Card has a unique ID number for you, which is not your Social Security number, or your Medicare number. Your unique ID number identifies you as a UPREHS Medicare HCPP & MSP plan member. Your UPREHS Health Insurance ID Card instructs participating physicians to send your Medicare claims to UPREHS HCPP. Nonparticipating providers will often send the Medicare Summary Notice to UPREHS for you if they have the information on your UPREHS ID card. You will use only your UPREHS ID card when obtaining prescriptions.
Your combined UPREHS Health Insurance and Rx ID Card does not guarantee coverage of all services or current eligibility. You or a provider can verify your eligibility and benefits by calling UPREHS Customer Services. The back of your card lists the UPREHS telephone number, claims mailing address and prescription drug plan information. If you should lose your card, you can obtain a replacement by calling UPREHS Customer Services at 1-800-547-0421. Remember, for 2008, UPREHS has a new P.O. Box mailing address, which is on your ID card!
This is how your combined UPREHS Health Insurance and Rx ID Card looks:
Help us keep your membership record up to date
UPREHS has a file containing your enrollment form, including your address and telephone number, and the address to mail your correspondence if different.
Please help us keep your membership record up to date by letting Customer Services know right away if there are any changes in your name, address, or phone number. Also, tell Customer Services about any changes in health insurance coverage you have from other sources, such as from your employer, your spouse's employer, workers’ compensation, Medicaid, or liability claims such as claims against another driver in an automobile accident. Medicare law requires us to keep this information current. Call UPREHS Customer Services at 1-800-547-0421.
UPREHS participating or in-network providers
The UPREHS MSP pays covered benefits to UPREHS participating providers at 100 percent of the allowed amount that Medicare did not pay (known as the coinsurance), and the Medicare annual deductible amount for covered benefits. A UPREHS participating provider is a physician, hospital, or other health care provider who has signed an agreement with UPREHS. UPREHS participating providers do not discount Medicare services, but they do agree to participate with the UPREHS HCPP and accept the Medicare allowed amount as payment in full for their services. They give discounts to UPREHS for non-Medicare services and agree to many service and quality stipulations. Very rarely a UPREHS participating physician will not participate with Medicare. In this case, UPREHS will make MSP payment up to the limiting charge for the covered services. Remember that not all UPREHS participating providers are able to take new patients at all times.
Nonparticipating or out-of-network providers
You may be partly or totally financially responsible for charges that Medicare did not pay from nonparticipating providers. The UPREHS MSP reduces payment to 40% of the Medicare coinsurance and annual deductible amount for covered benefits from UPREHS nonparticipating providers. A UPREHS nonparticipating provider is a physician, hospital, or other health care provider who has not signed a UPREHS participation agreement. UPREHS does not know if these providers participate with Medicare or not. (For exceptions, see Emergency and Urgent Care in the UPREHS Medicare Plan Benefits Chart in Section 4 and Benefit Exclusions in Section 5.) Your Original Medicare continues to cover services from providers who do not participate with UPREHS.
CAUTION! The UPREHS MSP nonparticipating provider payment reduction applies to the Medicare Part A and B coinsurance and the annual Medicare Part B deductible. This reduction can be very costly to you when it is applied to large amounts such as hospital bills and annual deductible. It is in your best interest to receive your services from UPREHS participating providers.
Covered services or covered benefits are the general term we use in this booklet to mean all of the health care services and supplies that are covered by Original Medicare and/or the UPREHS MSP.
Does the UPREHS HCPP have a geographic service area?
UPREHS now has over 450,000 participating providers across America including Alaska and Hawaii. Most states have a complete UPREHS participating provider network. You are free to obtain services from any UPREHS participating provider in any State and still be in-network and receive maximum benefit payment. If you go out of the UPREHS network to a nonparticipating provider, you will receive your Original Medicare benefits but your UPREHS MSP benefits will be reduced to 40 percent.
However, as a UPREHS Medicare member, you continue receiving benefits under the Original Medicare program so you are also free to obtain services according to your Original Medicare American boundaries and foreign travel restrictions.
To get a list of UPREHS participating providers
You can obtain a list of, or verify current UPREHS participating providers for any area you need on the UPREHS Website at www.uphealth.com (click on Search for a Provider) or by calling Customer Services at 1-800-547-0421. If you have any questions about, or need to verify the participation status of a provider, Customer Services can give you the most up-to-date information.
Find UPREHS participating providers when you travel
Locate UPREHS participating providers and hospitals in the travel area before you travel away from home. You can print a participating provider directory for any area from our Website at www.uphealth.com (click on Search for a Provider), or call UPREHS Customer Services at 1-800-547-0421 and we will print a directory and mail it to you. If you are traveling by car, consider finding participating providers in all areas that you will travel through, as well as at your destination.
Access to your personal information
You have the right to get full information from your doctors when you go for medical care. You have the right to participate fully in decisions about your health care, which includes the right to refuse care.
Primary Care Provider (PCP)
Your UPREHS plan does not require that you use a PCP, but we do recommend that you establish one to help you with your healthcare decisions. Besides providing much of your care, a PCP will help arrange or coordinate your x-rays, laboratory tests, therapies, care from doctors who are specialists, hospital admissions, and follow-up care. Primary care provider specialties are usually family practice, general practice, gynecology, geriatric medicine, or internal medicine.
What to do if you have a medical emergency or urgent need for care
In an emergency, you should get care immediately. You do not have to contact a UPREHS participating physician or get permission from anyone in an emergency. You can call 911 for immediate help by phone or go directly to the nearest emergency room, hospital, or urgent care center. Section 3 tells what to do if you have a medical emergency or urgent need for care.
UPREHS does not require referral for getting care from specialists
UPREHS does not require you to have any type of referral to see a specialist. You should make certain the specialist you need to see is UPREHS participating so that your MSP benefits are not reduced. Even if a UPREHS participating doctor sends you to a UPREHS nonparticipating specialist, your MSP benefits are reduced.
A specialist is a doctor who provides health care services for a specific disease or part of the body. Examples include oncologists (who care for patients with cancer), cardiologists (who care for patients with heart conditions), and orthopedists (who care for patients with certain bone, joint, or muscle conditions).
What if your doctor stops participating with UPREHS?
Sometimes a doctor, specialist, clinic, or other UPREHS participating provider you are using might stop participation with UPREHS. If this happens, you will have to switch to another provider who is participating to receive maximum UPREHS MSP benefits. Original Medicare benefits still cover services from providers who are not participating with UPREHS.
Can your benefits change during the year?
The Medicare program has rules about when we can make changes in your benefits. We can increase your benefits at any time during the calendar year. Here are some examples:
- If we decide to add a new benefit, this would be an increase in your benefits (even though you might have to pay something if you use the new benefit).
- If we decide to provide more of some benefit than you already have, this would be an increase in your benefits.
- If we decide to reduce the amount of a copayment, or plan premium, this would also be an increase in your benefits because you would be getting the same benefits for less money.
The Medicare program does not allow us to decrease your benefits during the calendar year. We are allowed to decrease your benefits only on January 1, at the beginning of the next calendar year. The Medicare program must approve any decreases we make in your benefits. We will tell you in advance if there are going to be any increases or decreases in your benefits for the next calendar year that begins on January 1, 2009.
At any time during the year, the Original Medicare program can change its national coverage. Since, with a few exceptions, we cover what Original Medicare covers, we would have to make any change that the Medicare program makes. These changes could be to increase or decrease your benefits, depending on what change the Original Medicare program makes.
Last Updated: 04/16/2008 |
UPREHS. Plan for Life.™ 
