Coordination of Benefits – HMSA and Medicare Plans – Pharmacy

Determining Primacy

When a member is covered by an HMSA group plan and Medicare, federal laws and regulations are applied to determine which coverage is primary for the patient. These rules apply to the working aged, the disabled, and patients with end-stage renal disease (ESRD).

People qualify for Medicare due to any of the following situations: age, disability or end-stage renal disease (ESRD). Following are conditions that apply to each of the three qualifying situations and affect coordination of benefits:

Age (for recipients age 65 or older)

The HMSA plan is primary if all of the following conditions are true:

• The patient has Medicare Part A or Parts A and B.
• The subscriber of the group plan is actively employed by his or her company (i.e. contributes to FICA).
• The subscriber’s employer has 20 or more part- or full-time employees.

Disability (for recipients younger than age 65 who qualify because of a disability, but who have not been diagnosed with chronic renal failure)

The HMSA plan is primary if all of the following conditions are true:

• The patient has Medicare Part A or Parts A and B.
• The subscriber of the group plan is actively employed by his or her company (i.e. contributes to FICA).
• The subscriber’s employer has 100 or more part- or full-time employees. (If the group insurance is a multi-employer plan, such as a union plan that covers employees of various companies, then this condition is met if at least one company in the group has 100 or more employees.)

End-stage Renal Disease (for recipients who qualify because they have been diagnosed with ESRD)

Medicare establishes an “ESRD date” that is the first of the month in which the patient was diagnosed with chronic renal disease. Three months after the ESRD date, Medicare coverage begins. For 30 months following the date Medicare coverage begins, Medicare is secondary to any group plan. After these 30 months have passed, Medicare becomes the primary plan.

Claims Filing Information

To comply with the law, please file appropriate claims to Medicare.

Pharmacies that do not contract with Medicare must follow these steps when Medicare is primary:

• The member must pay in full at the time of purchase for Medicare-covered drugs.
• The pharmacy will collect payment and give a receipt to the member.
• The pharmacy will file the claim with Hawaii’s Medicare Part B carrier, Blue Cross and Blue Shield of North Dakota.
• Pharmacies are required to be compliant with Medicare’s prescription documentation requirements as listed in the DMERC Region D Supplier Manual, and must contact the DMERC for Region D, CIGNA, if they do not have a Medicare provider number.
• Medicare will send payment and an Explanation of Medicare Benefits (EOMB) to the member.
• The member should send a copy of the EOMB and pharmacy receipt to HMSA’s Customer Service Department.
• HMSA will coordinate benefits and send payment to the member.

Revision History