State Codes and Statutes

State Codes and Statutes

Statutes > North-carolina > Chapter_135 > GS_135-45_10

§ 135‑45.10.  Personseligible for Medicare; optional participation in other Medicare products.

(a)        Benefits payablefor covered expenses under this Plan in G.S. 135‑45.6 through G.S. 135‑45.10will be reduced by any benefits payable for the same covered expenses underMedicare, so that Medicare will be the primary carrier except where compliancewith federal law specifies otherwise.

(b)        For thoseparticipants eligible for Medicare, the Plan will be administered on a"carve out" basis. The provisions of the Plan are applied to thecharges not paid by Medicare (Parts A & B). In other words, those chargesnot paid by Medicare would be subject to the deductible and coinsurance of thePlan just as if the charges not paid by Medicare were the total bill.

(c)        For thoseindividuals eligible for Part A (at no cost to them), benefits under thisprogram will be reduced by the amounts to which the covered individuals wouldbe entitled to under Parts A and B of Medicare, even if they choose not toenroll for Part B.

(d)        Notwithstanding theforegoing provisions of this section or any other provisions of the Plan, theExecutive Administrator and Board of Trustees may enter into negotiations withthe Centers for Medicare and Medicaid Services, U.S. Department of Health and HumanServices, in order to secure a more favorable coordination of the Plan'sbenefits with those provided by Medicare, including but not limited to,measures by which the Plan would provide Medicare benefits for all of itsMedicare‑eligible members in return for adequate payments from thefederal government in providing such benefits. Should such negotiations resultin an agreement favorable to the Plan and its Medicare‑eligible members,the Executive Administrator and Board of Trustees may, after consultation withthe Committee on Employee Hospital and Medical Benefits, implement such anagreement which shall supersede all other provisions of the Plan to thecontrary related to its payment of claims for Medicare‑eligible members.

(e)        Notwithstandingsubsections (a), (b), and (c) of this section, the Plan may offer an optionalMedicare Advantage plan to a Medicare eligible Plan member. A MedicareAdvantage plan offered by the Plan shall be an insured product offered througha private insurance carrier authorized by the Centers for Medicare and MedicaidServices to offer Medicare Advantage plans. A Medicare Advantage plan offeredby the Plan shall not be a self‑funded benefit plan underwritten by theState of North Carolina. Prescription drug benefits shall not be included inthe benefits offered under a Medicare Advantage insurance product but shallcontinue to be provided by the Plan as authorized under G.S. 135‑45.6.

An eligible Plan member maychoose to enroll in a Medicare Advantage plan in lieu of any other benefitcoverage plan offered under the Plan to Medicare eligible Plan members. AMedicare eligible Plan member must be enrolled in Medicare Part B toparticipate in an optional Medicare Advantage plan. A non‑Medicareeligible dependent of a Medicare Advantage eligible Plan member may enroll on afully contributory basis in benefit plans offered under the Plan to non‑Medicareeligible Plan members. If an enrolled Plan member decides not to re‑enrollin an optional Medicare Advantage plan during the Plan's annual enrollmentperiod, the Plan member may at that time re‑enroll in other benefitcoverage offered by the Plan in accordance with the provisions of subsections(a), (b), and (c) of this section.  (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1985 (Reg.Sess., 1986), c. 1020, s. 18; 1987, c. 857, s. 21; 1989, c. 752, s. 22(o); 2008‑168,ss. 1(a), 3(a), (o).)