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How the Consumer Driven Option works with Medicare

In general, if you or your spouse are working, the APWU Health Plan Consumer Driven Option is your primary health plan and Medicare is secondary.

If both you and your spouse are retired, Medicare is your primary coverage and APWU Health Plan is secondary.

When you are enrolled in Medicare, your provider will submit a claim to Medicare. After Medicare pays, they will submit the paperwork directly to the APWU Health Plan. As a member, you will not need to do any paperwork.

IMPORTANT

A doctor who has opted out of the Medicare program cannot bill services to Medicare. Often, these doctors will ask patients to sign a private contract for services covered by Medicare. If this happens, you may be responsible for any or all costs not covered by APWU Health Plan.

Part A and the Consumer Driven Option
Hospital services
  • In general, members with Medicare Part A as their primary insurance do not need to pre-certify hospital stays.
  • A stay must be pre-certified prior to the 90th day of confinement in a benefit period.


Worldwide coverage

Medicare generally doesn’t pay for hospital or medical services outside of the United States. Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands are part of the United States. But APWU Health Plan’s Consumer Driven Option coverage travels with you around the world. When you have services outside the U.S., you will probably have to pay the bill at the time of service. Save your receipts and submit a bill directly for reimbursement.

Part B and the Consumer Driven Option

When an APWU Health Plan Consumer Driven Option member is enrolled in Medicare Part B, Medicare pays first and the Plan is billed the remaining cost. The deductibles and coinsurance are not waived.

Medicare-participating doctors and suppliers

Medicare usually pays for covered services directly at 80% after the Medicare Part B annual deductible has been satisfied. If benefit dollars are available in your Personal Care Account (PCA), the Medicare deductible and coinsurance will be paid for covered services.

If your provider accepts Medicare, the provider will reduce the charge to no more than the Medicare allowance. You pay nothing for the covered charges up to our allowance.

Part C and the Consumer Driven Option

Medicare Part C – also called Medicare Advantage Plans – are private health plans that are Medicare-approved. As a member of the APWU Consumer Driven Option Plan, there is no need for you to enroll in Part C.

Part D and the Consumer Driven Option

Part D is Medicare’s prescription drug program. Prescription coverage is an integral part of your total health benefits package with APWU Health Plan. As a member of the APWU Consumer Driven Option Plan, your prescription drug benefit can exceed that of Medicare Part D. Therefore, there is no need for you to take part in Medicare Part D.

If you do enroll in Part D, you will need to use a network pharmacy and present both prescription drug ID cards when filling a prescription at a retail pharmacy. If you use a mail-order pharmacy through your Medicare prescription drug plan, submit a claim to APWU Health Plan with a copy of your Medicare Explanation of Benefits and your pharmacy receipt.

Medicare limiting charge

All insurance carriers in the Federal Employees Health Benefits (FEHB) program are mandated by law to limit payments for retired members 65 and older who do not have Medicare. Providers absorb these payment reductions. You are responsible only for deductibles, coinsurance, amounts over reasonable and customary limits, and non-covered charges.

More about Medicare and the Consumer Driven Option