Noblesville Schools Medical Plan 87 Section 7: Coordination of Benefits What is an allowable expense? For purposes of COB, an allowable expense is a health care expense that is covered at least in part by one of the health benefit plans covering you. When the provider is a Network provider for both the Primary Plan and this Plan, the allowable expense is the Primary Plan's network rate. When the provider is a network provider for the Primary Plan and an out- of-Network provider for this Plan, the allowable expense is the Primary Plan's network rate. When the provider is an out-of-Network provider for the Primary Plan and a Network provider for this Plan, the allowable expense is the reasonable and customary charges allowed by the Primary Plan. When the provider is an out-of-Network provider for both the Primary Plan and this Plan, the allowable expense is the greater of the two Plans' reasonable and customary charges. If this plan is secondary to Medicare, please also refer to the discussion in the section below, titled " Determining the Allowable Expense When this Plan is Secondary to Medicare ". What is Different When You Qualify for Medicare? Determining Which Plan is Primary When You Qualify for Medicare As permitted by law, this Plan will pay Benefits second to Medicare when you become eligible for Medicare, even if you don't elect it. There are, however, Medicare-eligible individuals for whom the Plan pays Benefits first and Medicare pays benefits second: • Employees with active current employment status age 65 or older and their Spouses age 65 or older (however, domestic partners are excluded as provided by Medicare). • Individuals with end-stage renal disease, for a limited period of time. • Disabled individuals under age 65 with current employment status and their Dependents under age 65. Determining the Allowable Expense When this Plan is Secondary to Medicare If this Plan is secondary to Medicare, the Medicare approved amount is the allowable expense, as long as the provider accepts reimbursement directly from Medicare. If the provider accepts reimbursement directly from Medicare, the Medicare approved amount is the charge that Medicare has determined that it will recognize and which it reports on an "explanation of Medicare benefits" issued by Medicare (the "EOMB") for a given service. Medicare typically reimburses such providers a percentage of its approved charge - often 80%. If the provider does not accept assignment of your Medicare benefits, the Medicare limiting charge (the most a provider can charge you if they don't accept Medicare - typically 115% of the Medicare approved amount) will be the allowable expense. Medicare payments, combined with Plan Benefits, will not exceed 100% of the allowable expense. If you are eligible for, but not enrolled in, Medicare, and this Plan is secondary to Medicare, or if you have enrolled in Medicare but choose to obtain services from a provider that does not participate in the Medicare program (as opposed to a provider who does not accept assignment of Medicare benefits), Benefits will be paid on a secondary basis under this Plan and will be determined as if you timely enrolled in Medicare and obtained services from a Medicare participating provider. When calculating the Plan's Benefits in these situations, and when Medicare does not issue an EOMB, for administrative convenience the Claims Administrator will use Medicare's Allowable Expense or Medicare's limiting charge for covered services as the Allowable expense for both the Plan and Medicare. Medicare Crossover Program The Plan offers a Medicare Crossover program for Medicare Part A and Part B and Durable Medical Equipment (DME) claims. Under this program, you no longer have to file a separate claim with the Plan to receive secondary benefits for these expenses. Your Dependent will also have this automated Crossover, as long as he or she is eligible for Medicare and this Plan is your only secondary medical coverage.