I will put questions and answers in this article for Legacy T retirees.

Q) How will payment of the co-insurance work when you visit the doctor, lab, or hospital? Will the office make some calculation on the spot or will the claim be filed and the employee be billed once it is processed?

A) That will depend on whether the doctor’s office has online adjudication with the carriers. However, generally it is advisable to tell the clerk at the doctor’s office to submit the claim to the carrier first, have it adjudicated by the administrator so that the charges are reduced to the network amount, then to bill the participant after the insurance claims administrator determines the benefits. This is true whether the claim is in the deductible amount or in coinsurance. The participant should not pay at the point of service because the claim must have the network discounts applied prior to payment.

If the doctor’s office has online adjudication with the carrier, then the individual can pay at the point of service. When leaving the office after services are rendered, if the participant is asked to pay an amount, the participant should ask if the office has online adjudication capabilities with the administrator and for them to verify that the amount requested is after the application of either the deductible or coinsurance. If the answers are yes to both questions, then the participant may pay at the point of service.



Q) It is my understanding, when spouses are different ages, and one is post-65 and the other is pre-65, that each chooses from the option available in the category that goes with their age (Medicare eligibility). Is that correct?

A) Yes, that is correct.