THE SENIOR CITIZEN HEALTH PROGRAM — A PROGRAM TO COMPLEMENT YOUR MEDICARE COVERAGE
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How This Program Works with Medicare
The Senior Citizen Health Program will provide you and your Medicare-eligible dependents with coverage secondary to Medicare. Reimbursement for services covered by Medicare will be based on the difference between the amounts paid by Medicare and the amounts allowed by Medicare (not the actual provider charge). In no event will the AFTRA Health Plans pay more than the covered charges as determined by the Medicare allowances (less what Medicare paid). Reimbursement for services not covered by Medicare will be paid according to the provisions of the AFTRA Health Plans. Since Medicare is the primary payer, before the Health Plan begins to pay benefits, you must meet the non-network deductible.
Under some circumstances, certain providers opt out of Medicare and must alert their patients to that effect. If your provider does not accept Medicare, and you proceed to incur charges with that provider, it will be treated as if you have chosen not to file a claim with Medicare and your claim will be processed as if you had received benefits from Medicare (see next section).
If You are Not Eligible for Medicare or You Do not File a Claim with Medicare
Whether or not you are covered by Medicare, the Senior Citizen Health Program will reimburse you for Plan covered expenses as if you had received benefits from Medicare. See “Coordination with Medicare”.
If You Are a Resident of Another Country
If you live in another country, the Senior Citizen Health Program will reimburse you for your Plan covered medical expenses as though you had received benefits from Medicare.
If Medicare Days are Exhausted
If during your hospitalization you use up all your available Medicare days, the AFTRA Health Plans will pay for medically necessary additional Plan covered hospital days at the Medicare rate. Any amounts charged by the hospital that are above the Medicare rate will not be paid by the AFTRA Health Plans. These additional days must be medically necessary and be overseen by Alicare Medical Management (AMM), the company which administers under contract our Case Management program.
If You Use a Veteran’s Administration (VA) Hospital
If you are Medicare eligible and receive treatment at a hospital operated by the Veterans’ Administration for an illness or injury which is not related to military service, the medical benefits paid by the AFTRA Health Plans will be the amount you would have received if the service had been provided in a non‑governmental facility with Medicare as the primary payor.
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How This Program Works with Medicare
The Senior Citizen Health Program will provide you and your Medicare-eligible dependents with coverage secondary to Medicare. Reimbursement for services covered by Medicare will be based on the difference between the amounts paid by Medicare and the amounts allowed by Medicare (not the actual provider charge). In no event will the AFTRA Health Plans pay more than the covered charges as determined by the Medicare allowances (less what Medicare paid). Reimbursement for services not covered by Medicare will be paid according to the provisions of the AFTRA Health Plans. Since Medicare is the primary payer, before the Health Plan begins to pay benefits, you must meet the non-network deductible.
Under some circumstances, certain providers opt out of Medicare and must alert their patients to that effect. If your provider does not accept Medicare, and you proceed to incur charges with that provider, it will be treated as if you have chosen not to file a claim with Medicare and your claim will be processed as if you had received benefits from Medicare (see next section).
If You are Not Eligible for Medicare or You Do not File a Claim with Medicare
Whether or not you are covered by Medicare, the Senior Citizen Health Program will reimburse you for Plan covered expenses as if you had received benefits from Medicare. See “Coordination with Medicare”.
If You Are a Resident of Another Country
If you live in another country, the Senior Citizen Health Program will reimburse you for your Plan covered medical expenses as though you had received benefits from Medicare.
If Medicare Days are Exhausted
If during your hospitalization you use up all your available Medicare days, the AFTRA Health Plans will pay for medically necessary additional Plan covered hospital days at the Medicare rate. Any amounts charged by the hospital that are above the Medicare rate will not be paid by the AFTRA Health Plans. These additional days must be medically necessary and be overseen by Alicare Medical Management (AMM), the company which administers under contract our Case Management program.
If You Use a Veteran’s Administration (VA) Hospital
If you are Medicare eligible and receive treatment at a hospital operated by the Veterans’ Administration for an illness or injury which is not related to military service, the medical benefits paid by the AFTRA Health Plans will be the amount you would have received if the service had been provided in a non‑governmental facility with Medicare as the primary payor.
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