The Plan will pay 100 percent of the remaining balance after Medicare processes the claim based on the Medicare allowance for covered services. If Medicare does not cover a service and it is a covered service under the Plan, the Plan will pay at 100 percent of the Plan's allowance.
Regular Plan benefits will apply for dependents who are not eligible for Medicare.
Wellness benefits for Medicare primary participants will pay at 100 percent of the Plan allowance for covered services if Medicare denies the service. If Medicare pays for the service, the Plan will pay 100 percent of the balance remaining after the Medicare payment. Wellness benefits are not subject to network or out-of-network differentials for Medicare primary participants.
Emergency room and telehealth provider visit copayments will not apply to participants who are Medicare primary.
Medicare eligible participants are not required to pre-certify medical services through Acentra unless Medicare does not cover the service.
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