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This NMMIP Carve-Out Plan is designed to
“coordinate” benefits with Medicare and usually
pays benefits only after Medicare has paid its
portion of your covered health care services.
Medicare is called the “primary” coverage or
carrier and pays its benefits first.
The NMMIP is the “secondary” coverage or
carrier. You may not elect to change NMMIP
to be the primary carrier and may not elect to
bypass Medicare. If services are among those
normally covered by Medicare, you or your doctor
or hospital (your health care “provider”) must
submit a claim for those services first to
Medicare. Medicare will calculate its benefits
and will send you an Explanation of Medicare
Benefits (EOMB) form. This form must be attached
to any claim you send to the NMMIP
Administrator. Note: You will usually not have
to submit claims.
Services Covered Only by NMMIP — A
service covered under this Policy may not be
covered by Medicare either because it is not a
covered type of service under Medicare (such as
acupuncture) or because it is from a provider
that is not covered by Medicare (such as a
nonparticipating hospital). When such services
are covered under this NMMIP Policy, you can
choose to visit any eligible health care
provider you want and still receive benefits as
listed. However, there are advantages to
choosing a health care provider that has a
participating provider agreement with the
Administrator. These providers will not bill you
for amounts that are over the Administrator’s
maximum allowable fee (or covered charge).
Note: Some services not covered by
Medicare will be denied or benefits for them
reduced if you do not obtain prior approval from
the Administrator.
Services Covered Only By Medicare — This
Carve-Out Plan will cover Medicare-eligible
services that are also listed as covered in the
Summary of Benefits on pages iv and v. However,
some benefits are limited under the NMMIP Policy
and benefit payments cannot exceed those limits
– even if Medicare covers the service.
[Click
Here] to review the Summary of Benefits for
the Medicare Carve Out Plan. |
