R2000-207 AUTHORIZING APPLICATIONS

Home Browse Search

and payment for, such health care services. Under such circumstances the Blue Cross and � Blue Shield Plan in the particular state in which such services are received (the"Host Plan") � will process the Covered Person's Claim in accordance with the Host Plan's applicable con- tract, if any, with the particular Provider ("Host Plan Provider"). Host Plans may charge the Claim Administrator an access fee for making their negotiated payment rates and the resulting savings available on Claims incurred by Covered Persons under this Agreement. This Blue- Card access fee may be up to 10% (but not to exceed $2,000 for any Claim) of the resulting savings. When the Claim Administrator is charged an access fee by a Host Plan for such services,such fee shall be considered and treated as a Claim Payment under this Agreement. If the Claim Administrator receives any credit relative to such access fee from the Host Plan, such amount shall be credited against Claim Payments under this Agreement. Instances may occur in which no Claim Payment or a minimal Claim Payment is made under this Agreement because the amounts eligible for payment were applied to the deductible or Coinsurance. Nonetheless, if the Host Plan charges the Claim Administrator an access fee as discussed above relative to such Claim, the Claim Administrator shall pay such fee and such amount shall be considered and treated as a Claim Payment under this Agreement. The Claim Administrator hereby informs the Employer, and the Employer acknowledges, that the Claim Administrator's and the Host Plans'Provider contracting arrangements, operational practic- es and procedures, and the policies and procedures governing Inter-Plan Teleprocessing Soft- ware(ITS)software used to process Claims for services rendered by the Claim Administrator's and the Host Plans' Providers may result in minor deviations in Claim processing and/or pricing of Claims for same services. The Employer represents that it has included the provision stated in this Section XVII. in its Plan Document. XVIII. MEDICARE SECONDARY PAYER ("MSP") PROVISIONS A. The MSP Law The Employer has certain obligations under the Medicare Secondary Payer ("MSP")statute. 1. Scope of the Statute: The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan ("GHP") coverage, as well as certain otherfac- tors, including the size of the employers sponsoring the GHP. In general, Medicare pays secondary to the following: a. GHPs that cover individuals with end-stage renal disease ("ESRD") during the first 30 months of Medicare eligibility or entitlement. This is the case regardless of the number of employees employed by the employer or whether the individual has"cur- rent employment status." b. In the case of individuals age 65 or over, GHPs of employers that employ 20 or more employees if that individual or the individual's spouse (of any age) has"current em- ployment status."If the GHP is a multi-employer or multiple employer plan,which has at least one participating employer that employs 20 or more employees, the MSP rules apply even with respect to employers of fewer than 20 employees (unless the ' ! � plan elects the small employer exception under the statute). c. In the case of disabled individuals under age 65,GHPs of employers that employ 100 ' or more employees, if the individual or a member of the individual's family has"cur- rent employee status." If the GHP is a multi-employer or multiple employer plan, , - 12 - I�I