We will be contacting Medicare-eligible members in Pennsylvania to communicate the Medicare Exclusion and how this exclusion applies to their benefit plan.

What is the Medicare Exclusion?

Pennsylvania members who are eligible for Medicare and for whom Medicare would be the primary payer will be responsible for paying their doctor, hospital, or other medical professional the amount Medicare would have paid and any applicable copayment, coinsurance, or deductible. In turn, their group health benefit plan will only pay the remaining balance on claims submitted as if the member had enrolled in Medicare Parts A and B.

Who is eligible for Medicare?

Individuals who are eligible for Medicare, include: Most people 65 and older. Generally people are Medicare-eligible if they or their spouse worked for at least ten years in a Medicare-covered employment and are 65 or older and a citizen or permanent resident of the United States. Note: People are eligible for Medicare when they turn 65, even if they are not eligible for Social Security retirement benefits. Some people younger than 65. People younger than 65 who have certain disabilities and illnesses, such as Lou Gehrig?s disease (ALS) or other disabilities for which people are eligible for Social Security Disability benefits. People with kidney failure. People of any age with kidney failure who require dialysis or a kidney transplant. If your patients have questions about eligibility for Medicare Part A or Part B or want to apply for Medicare, they should call Social Security at 1-800-772-1213 or visit or call their local Social Security office. TTY users should call 1-800-325-0778. They can also get information about buying Part A as well as Part B if they do not qualify for premium-free Part A.