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.)

Last Update: 04/11/2008