The NMMIP Medicare Carve-Out Plan is available to individuals under the age of 65 who are enrolled in Medicare due to a disability. You must have both Medicare Part A and Part B to be eligible for the Carve-Out Plan.
Coordination of Benefits
The 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.