PSHB FEP Blue Focus
2026 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 9. Coordinating Benefits With Medicare and Other Coverage
Page 122
Section 9. Coordinating Benefits With Medicare and Other Coverage
Page 122
When the Original Medicare Plan is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for the covered charges. To find out if you need to do something to file your claims, call us at the customer service phone number on the back of your ID card or visit our website at www.fepblue.org.
You will pay what Medicare says you owe for services subject to the calendar year deductible up to $750 per person under a self only or self + one contract, or a combined $1,500 under a self and family contract. Once you have satisfied the deductible, we will provide benefits as follows:
When Medicare Part A is primary –
Note: We do not waive benefit limitations, such as the 10-visit limit for home skilled nursing visits. In addition, we do not waive any coinsurance or copayments for prescription drugs.
You can find more information about how our Plan coordinates benefits with Medicare in our Medicare and You Guide for Federal Employees available online at www.fepblue.org.
You will pay what Medicare says you owe for services subject to the calendar year deductible up to $750 per person under a self only or self + one contract, or a combined $1,500 under a self and family contract. Once you have satisfied the deductible, we will provide benefits as follows:
When Medicare Part A is primary –
- Once you have exhausted your Medicare Part A benefits, you must then pay the coinsurance once the calendar year deductible has been satisfied for the inpatient admission.
Note: Precertification is required.
Note: We do not waive benefit limitations, such as the 10-visit limit for home skilled nursing visits. In addition, we do not waive any coinsurance or copayments for prescription drugs.
You can find more information about how our Plan coordinates benefits with Medicare in our Medicare and You Guide for Federal Employees available online at www.fepblue.org.
• Tell us about your Medicare coverage
You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.
You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.
• Private contract with your physician
If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after Original Medicare’s payment. You may be responsible for paying the difference between the billed amount and the amount we paid.
If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after Original Medicare’s payment. You may be responsible for paying the difference between the billed amount and the amount we paid.
• Medicare Advantage (Part C)
If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), TTY: 711, or at www.medicare.gov. If you enroll in a Medicare Advantage plan, the following options are available to you.
This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s non-PSHB Medicare Advantage plan and also remain enrolled in our PSHB Plan. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.
We provide benefits for care received from Preferred providers when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area. Please remember that you must receive care from Preferred providers in order to receive benefits. See Section 3 for the exceptions to this requirement.
Suspended PSHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your PSHB coverage to enroll in a Medicare Advantage plan, eliminating your PSHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your PSHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the PSHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.
If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), TTY: 711, or at www.medicare.gov. If you enroll in a Medicare Advantage plan, the following options are available to you.
This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s non-PSHB Medicare Advantage plan and also remain enrolled in our PSHB Plan. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.
We provide benefits for care received from Preferred providers when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area. Please remember that you must receive care from Preferred providers in order to receive benefits. See Section 3 for the exceptions to this requirement.
Suspended PSHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your PSHB coverage to enroll in a Medicare Advantage plan, eliminating your PSHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your PSHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the PSHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.