April 16, 1980
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Disputes
Case No. 102
Pursuant to Article IX of the UMWA 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the U.S. Department of Labor, the Trustees have received a question concerning copayments of medical bills by participants who are Medicare eligible. Their opinion is issued in Question and Answer form, as follows:
Subject: Medicare Deductible
Question: Will the Funds pay for any part of the $60.00 Medicare Part B deductible?
Answer: A Beneficiary submits to the Funds a Medicare Explanation of Benefits from his/her Part B Medicare carrier indicating that he/she has met some or all of his/her $60.00 deductible and, as necessary, supporting invoices from provider(a) indicating services rendered. The Funds will determine the number of visits associated with the E.O.B., will deduct the appropriate copayment per visit and remit to the Beneficiary the balance (unless the copayment maximum has been met within the calendar year). If the Funds’ copayment maximum has been previously met, the entire amount indicated on the E.O.B. will be remitted to the Beneficiary.
According to the provisions of this Question and Answer, a Beneficiary is only required to meet the $100.00 copayment required per calendar year per family for physician services. Therefore, once some or all of the deductible has been met under Medicare the Employer might determine from the services associated with the Medicare coverage the applicable number of copayments to be deducted under the Employer’s Plan. Once that determination has been made, the Employee is responsible for the copayments required under the Employer’s Plan until the maximum of $100.00 has been met. At no time should an Employee who is Medicare eligible be paying more than the $100.00 copayment required under the Employer’s Plan.