MEDICARE AND THIS CONTRACT Clause Samples

MEDICARE AND THIS CONTRACT. ‌ Medicare is a primary payer for Medicare enrollees who are eligible for Medicare because (a) they have reached age 65, or (b) are under age 65, and covered by Medicare because of disability or end stage renal disease. The benefits under this Contract are not intended to duplicate any benefits to which members are, or would be, entitled under Medicare. All sums payable under Medicare for services provided pursuant to this Contract shall be payable to and retained by us. Each member shall complete and submit to us such consents, releases, assignments and other documents as may be requested by us in order to obtain or assure reimbursement under Medicare for which members are eligible. We also reserve the right to reduce benefits for any medical expenses covered under this Contract by the amount of any benefits available for such expenses under Medicare. This will be done before the benefits under this Contract are calculated. Charges for services used to satisfy a member’s Medicare Part B deductible will be applied under this Contract in the order received by us. Two or more charges for services received at the same time will be applied starting with the largest first. The benefits under this Contract are considered secondary to those under Medicare only when the member has actually enrolled in Medicare. The provisions of this section will apply to the maximum extent permitted by federal or state law. We will not reduce the benefits due any member due to that member’s eligibility for Medicare where federal law requires that we determine our benefits for that member without regard to the benefits available under Medicare. EFFECTIVE DATE AND ELIGIBILITY‌ EFFECTIVE DATE‌
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