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Paying the plan premium for your coverage as a member of the UPREHS Medicare Plans
What happens if you don’t pay your UPREHS plan premiums, or don’t pay them on time?
Can your plan premiums change during the year?
You must pay the full cost of services that are not covered
You must continue to pay your Medicare Part B premium
Coinsurance and/or deductible amounts
You will pay more to see nonparticipating providers
Please keep us up-to-date on any other health insurance coverage you have
Who pays first when you have additional insurance?
What should you do if you have bills from nonparticipating providers you think we should pay?
Paying the plan premium for your coverage as a member of the UPREHS Medicare Plans
AAll UPREHS Medicare members must be entitled to Medicare Part A and enrolled in Part B. Members must continue to pay the Medicare Part B monthly premium. If you pay a Medicare Part A premium (most people do not), you must continue paying that premium to be a member. Premium payments for membership in the UPREHS Medicare Plans include the Medicare Secondary Plan and the UPREHS Prime Medicare Plan pharmacy plan. Premiums are paid quarterly (three months at-a-time) to UPREHS. Quarterly premiums are paid to UPREHS by the first day of the month beginning on January 1, April 1, July 1, and October 1 of each year. Premium amounts are determined by the UPREHS Board of Trustees and can change at any time. You will receive at least 30 days notice of any changes enacted by the Board.
There is no additional or separate fee for membership in the UPREHS HCPP because you continue to pay your Original Medicare Part B monthly premium. The UPREHS Medicare HCPP makes the Original Medicare Part B payment to participating physicians. This is why CMS only authorizes UPREHS to make payment of HCPP benefits if you are enrolled in Original Medicare Part B. Premiums that are paid to UPREHS are for membership in the UPREHS Prime Medicare Plan Part D pharmacy plan and the UPREHS MSP. The UPREHS MSP pays the annual deductible and coinsurance after Original Medicare Part A and B have paid.
There are two ways to pay your monthly plan premium. - Option one - pay quarterly: Pay your Plan premium quarterly (3 months at a time) by check, money order, or automatic premium deduction from your checking or savings account. If you pay by check or money order, we must receive your payment by the first of the month of every January, April, July, and October beginning with January 1, 2008. If you choose automatic deductions, we will debit your bank account on the second Monday of every December, March, June, and September.
UPREHS charges a $20 service fee for checks returned or automatic premium payments rejected because of insufficient funds.
If you have any questions about signing up for the automatic premium payment option, to receive an authorization form, your Plan premiums or the different ways to pay them, please call our Customer Services at 1-800-547-0421.
- Option two - pay monthly: You can pay your Plan premium monthly through automatic premium deduction from your checking or savings account. We cannot accept monthly payments sent directly to UPREHS. We offer payment of your combined UPREHS Medicare Plans premiums monthly only if you have the amount automatically deducted from your bank account. If you do not have a checking account you can use your savings account. Monthly payments must be made through automatic bank account withdrawals. We cannot accept monthly payments sent directly to UPREHS.
If you have any questions about signing up for the automatic premium payment option, to receive an authorization form, your Plan premiums or the different ways to pay them, please call our Customer Services at 1-800-547-0421.
What happens if you don’t pay your UPREHS plan premiums, or don’t pay them on time?
If your quarterly premium payments are past due, you are automatically given a 30-day grace period. If you do not pay your past-due payment within the 30-day grace period, we will disenroll you. Disenrolling you ends your membership in the UPREHS HCPP, the Medicare Secondary Plan and the UPREHS Prime Medicare Plan Part D pharmacy program and you may not be allowed to enroll again. You will then have Original Medicare coverage. (Section 12 explains about disenrollment and Original Medicare coverage.)
Can your plan premiums change during the year?
The UPREHS Board of Trustees is allowed to increase or decrease the amount of your UPREHS Medicare Plan premiums only for your Medicare Secondary Plan at any time during the year. Premiums for your UPREHS Prime Medicare Plan Part D pharmacy program can only change at the first of each year. If the Board decides to increase or decrease your plan premium during the calendar year, or at the first of the year, we will let you know at least 30 days in advance in writing.
You must pay the full cost of services that are not covered
With very few exceptions, you are personally responsible to pay for care and services that are not covered by Original Medicare. If you obtain services, items and/or drugs that are not covered, you must pay for them yourself. There are some services and items that may be covered under Original Medicare, but are not covered under your UPREHS Medicare Plans. Other sections of this booklet tell about covered services and the rules that apply. UPREHS MSP payment is reduced to 40% for services you receive from UPREHS nonparticipating providers. The exceptions are care for a medical emergency or urgently needed care for the first 24 hours.
You must continue to pay your Medicare Part B premium
You must continue to pay your Medicare Part B monthly premium. Your UPREHS MSP and Prime Medicare Plan premiums are combined together and paid to UPREHS in addition to your Original Medicare Part B premiums.
Coinsurance and/or deductible amounts
Original Medicare Part A and B both require that you pay deductible and coinsurance amounts as your share of your medical bills. Your UPREHS MSP pays all of your Medicare coinsurance and deductible amounts for covered benefits when services are obtained from UPREHS participating providers. Your UPREHS MSP reduces payment to 40% for services from nonparticipating providers (see the UPREHS Medicare Plan Benefits Chart in Section 4). UPREHS participation does not affect the payment amount from Original Medicare.
Your UPREHS MSP does not require you to pay any coinsurance and/or deductible amounts in addition to those imposed by Original Medicare. You may be responsible for payment of some of the Medicare coinsurance and/or deductible amounts for services from nonparticipating providers or for UPREHS noncovered benefits.
You will pay more to see nonparticipating providers
Your out-of-pocket costs will be higher if you use nonparticipating providers than if you use participating providers. Original Medicare will pay for covered care that you get from nonparticipating providers. However, unless it was emergency care, you will pay more for the care you receive from nonparticipating providers. Your UPREHS MSP reduces payment to 40% for services from nonparticipating providers (see the UPREHS Medicare Plan Benefits Chart in Section 4). UPREHS participation does not affect the payment amount from Original Medicare.
In most cases, you will pay nothing to see UPREHS participating providers because these providers have an agreement with us to accept the Original Medicare amount as payment in full for services provided to you. There are a lot of doctors, hospitals, and other health care providers who are UPREHS participating providers. If you do not have a list of our providers and would like to have one, please call Member Services at 1-800-547-0421 or visit our Website at www.uphealth.com.
Please keep us up-to-date on any other health insurance coverage you have
USING ALL OF YOUR INSURANCE COVERAGE
If you have other health insurance coverage besides Original Medicare and the UPREHS Medicare Plans, Medicare law states that you must use this other coverage in combination with your coverage as a member to pay for the care you receive. This is called coordination of benefits because it involves coordinating all of the health benefits that are available to you. Using all of the coverage you have helps keep the cost of health care more affordable for everyone.
LET US KNOW IF YOU HAVE ADDITIONAL INSURANCE
You must tell us if you have any other health insurance coverage besides Original Medicare and the UPREHS Medicare Plans and let us know whenever there are any changes in your additional insurance coverage. The types of additional insurance you might have include the following: - Coverage that you have from an employer’s group health insurance for employees or retirees either through yourself or through your spouse.
- Coverage that you have under workers’ compensation because of a job-related illness or injury, or under the Federal Black Lung Program.
- Coverage you have for an accident where no-fault insurance or liability insurance is involved.
- Coverage you have through Medicaid.
- Coverage through the TRICARE for Life program (veteran’s benefits).
- Coverage you have for prescription drugs other than the UPREHS Prime Medicare Plan.
- Continuation coverage that you have through COBRA. COBRA is a law that requires employers with 20 or more employees to let employees and their dependents keep their group health coverage for a time after they leave their group health plan under certain conditions.
Who pays first when you have additional insurance?
When you have additional insurance coverage, how we coordinate your benefits as a member of Original Medicare and the UPREHS Medicare Plans with your benefits from other insurance depends on your situation. With coordination of benefits, you will often get your care as usual through Original Medicare, and the other insurance you have will simply help pay for the care you receive. In other situations, such as for benefits that are not covered by Original Medicare and/or UPREHS, it is possible that the other insurance could make payment.
The insurance company that pays its share of your bills first is called the primary payer. Then the other company or companies that are involved are called the secondary payers — each pays its share of what is left of your bills. Often your other insurance company will settle its share of payment directly with us and you will not have to be involved. However, if payment is owed to Medicare or to us and is sent directly to you, you are required under Medicare law to give this payment to Medicare or to us. When you have additional health insurance, whether we pay first or second— or at all— depends on what type or types of additional insurance you have and the rules that apply to your situation. Medicare sets many of these rules. Some of them take into account whether you have a disability or have End-Stage Renal Disease (permanent kidney failure), or how many employees are covered by an employer’s group insurance.
If you have additional health insurance, please call Medicare at 1-800-MEDICARE (1-800-633-4227) or UPREHS Customer Services at 1-800-547-0421 to find out which rules apply to your situation, and how payment will be handled. Also, the Medicare program has written a booklet with general information about what happens when people with Medicare have additional insurance. It’s called Medicare and Other Health Benefits: Your Guide to Who Pays First. You can get a copy by calling Medicare at 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048), or by visiting their Website at www.medicare.gov.
What should you do if you have bills from nonparticipating providers you think we should pay?
Original Medicare makes payment for your services from out-of-network nonparticipating providers and many other services of UPREHS participating providers. Your UPREHS MSP makes payment secondary to Medicare for the coinsurance and deductible amounts for covered benefits. The UPREHS MSP benefit payment is reduced to 40% for services from nonparticipating providers. The exception is care for a medical emergency or urgently needed care for the first 24 hours. If a nonparticipating provider asks you to pay for the Medicare coinsurance or deductible for covered services, please ask him to bill Medicare first. If you have already paid for the Medicare coinsurance or deductible amount for covered services we will reimburse you at the out-of-network reduced amount. If you received a bill for the services, you can send the bill along with your Medicare Summary Notice (MSN) to us for MSP payment. We will pay our share of the bill and let you know what, if anything, you must pay. You will not have to pay the nonparticipating provider any more than what is allowed for payment of covered services by Original Medicare.
Last Update: 04/22/2007 |
UPREHS. Plan for Life.™ 
