Operating Engineers Health & Welfare Fund

Important Basics About the Plan

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COORDINATION OF BENEFITS WITH MEDICARE

FOR ACTIVE MEMBERS AND SPOUSES

1.

 WHEN YOU OR YOUR SPOUSE CONTINUE TO WORK BEYOND AGE 65:

Medicare has special rules that apply to Medicare beneficiaries who are older than 65 and who have group health coverage through their own employment or the employment of a spouse.  

In such situations, Medicare will give you and your spouse the option to accept or reject coverage through the Health & Welfare Fund.

If you ACCEPT coverage through this Fund, the Fund will provide benefits as the primary carrier and Medicare will be secondary payer.

If you REJECT coverage through the Fund, Medicare will be the only health insurance payer.  The Fund would provide no benefits.

a.

 If you and your spouse are 65 or older, and both of you work and have health insurance through employment:
Member's Claim Operating Engineer's Health & Welfare Fund pays first; Spouse's insurance pays second; Medicare pays third.
Spouse's  Claim Spouse's insurance pays first; Operating Engineer's Health & Welfare Fund pays second; Medicare pays third.
b. If you and your spouse are 65 or older but only you (the member) work and have health insurance through your employment:
Member's Claim

Operating Engineer's Health & Welfare Fund pays first; Medicare pays

second.
Spouse's Claim Operating Engineer's Health & Welfare Fund pays first; Medicare pays second.
c. If you and your spouse are 65 or older but only your spouse works and has health insurance through her employment:
Member's Claim

Spouse's insurance pays first; Medicare pays second; Operating

Engineer's Health & Welfare Fund pays third.
Spouse's Claim Spouse's insurance pays first; Medicare pays second; Operating Engineer's Health & Welfare Fund pays third.

2.

 WHEN YOU ARE DISABLED AND UNDER AGE 65:

Medicare is the secondary payer for most disabled people who are covered by the Health & Welfare Fund or the employer health plan of an employed spouse or family member.  The Fund will provide benefits as the primary carrier and Medicare will be the secondary payer.

3.

 WHEN YOU HAVE MEDICARE BECAUSE OF KIDNEY DISEASE:

If you are entitled to Medicare solely because of end stage renal (kidney) disease (ESRD), the Fund is required to provide benefits as the primary carrier for 30 months, and Medicare will be the secondary payer.  When the 30 month period is over, Medicare will provide benefits as the primary carrier and the Fund will be the secondary payer.

4.

 WHEN YOU ARE COVERED BY THE WIDOW SELF-PAYMENT PLAN AND TURN 65:

When a widow reaches age 65, she will be covered by the Fund's Retiree Plan and Medicare will become the primary carrier at that time.

*Use Medicare-Participating Physicians and Suppliers*

Doctors and suppliers can now sign agreements to become Medicare-participating doctors and suppliers.  This means they have agreed in advance to accept assignment on all Medicare claims and this can reduce your out-of-pocket expenses.   

The names and addresses of Medicare-participating doctors and suppliers are listed in the "Medicare-Participating Physician/Supplier Directory."  This directory is available for review in all Social Security offices and in most hospitals.  You can also obtain the directory free of charge from your Medicare carrier.  The Medicare carrier will send a copy to you.

Using a Medicare-participating doctor or supplier can also save you time.  Medicare will pay the doctor directly so you do not have to handle all the paperwork involved with your claims.

The Fund will provide regular Plan benefits for services not covered by Medicare, but only if the services are covered by the Plan.  This would include hearing exams, hearing aids, chiropractors' services and flu shots.