Coordination of Benefits

The Plan coordinates benefits with other plans under which you and your Dependents may be covered for benefits, so that reimbursement from both plans never exceeds 100% of your allowable expenses.

If you or your Dependent is covered under more than one plan of group benefits, there may be instances where coverage is duplicated — two plans pay benefits for the same expenses. For that reason, a coordination of benefits provision has been adopted to coordinate the benefits payable as described in this booklet with similar benefits payable under other plans.

Under the Coordination of Benefits (COB) provision, if you or any of your Dependents are also covered under any other group plan, the total payments you will receive from all such programs combined will not amount to more than 100% of Allowable Expenses. Allowable Expenses are any Medically Necessary and Allowable Charges for medical services, treatment or supplies covered by one of the plans under which you or your Dependent is covered.

For COB purpose, plan means any program, other than individual insurance, that provides benefits or services for medical care or treatment through group insurance coverage or any other pre-payment or service type plan.

Determining Which Plan Pays First

If you or your Dependents are covered by another plan or plans, the benefits under this Fund and the other plan(s) will be coordinated. This means one plan pays its full benefits first, then the other plan or plans pay.

• The primary plan (which is the plan that pays benefits first) pays the benefits that would be payable under its terms in the absence of this provision.
  
  
• The secondary plan (which is the plan that pays benefits after the primary plan) will limit the benefits it pays so that the sum of its benefits and all other benefits paid by the primary plan will not exceed the greater of:
  
• 100% of total covered expenses, or
  
  
• The amount of benefits it would have paid had it been the primary plan.
  

If you or your Dependents are eligible under another plan, there are a few simple rules that determine the order in which benefits are paid.

• When another plan does not have a Coordination of Benefits provision (COB provision), that plan must determine benefits first.
  
  
• When another plan does have a COB provision, the first of the following rules that applies governs:
  
  
• If a plan covers the claimant as an active Employee, then that plan will pay its benefits first.
  
  
• For an Eligible Dependent child whose parents are not divorced or separated, the plan of the parent whose birthday (month and day) is earlier in the calendar year will pay first. If both parents’ birthdays are the same day, the last rule will apply.
  

The birthday rule provides that the plan of the parent with the birthday that occurs earlier in the year pays first. The birthday comparison is by month and day only and not by year. For example, the plan of a parent who is older but who has a December birthday will be secondary to the parent who may be younger but who has a birthday earlier in the year.

• For an Eligible Dependent child whose parents are divorced or separated, the following rules apply:
  
  
  • A plan that covers a child as a Dependent of a parent who by court decree must provide health coverage will pay first.
    
    
  • When there is no court decree that requires a parent to provide health coverage for a Dependent child, the following rules will apply:
    
    
    • When the parent who has custody of the child has not married, that parent’s plan will pay first and the non-custodial parent’s plan will pay second.
      
      
    • When the parent who has custody of the child has remarried, benefits will be determined by that parent’s plan first, by the stepparent’s plan second, and by the non-custodial parent’s plan third.
      
      
• If none of the above rules apply, the plan that has covered the claimant for the longest period of time will pay its benefits first, except:
  
  
  • When one plan covers the claimant as a laid-off or retired Employee (or a Dependent of such an Employee), and the other plan includes a COB rule for laid-off or retired Employees, the plan that covers the claimant as other than a laid-off or retired Employee (or a Dependent of such an Employee) will pay first,
    
    
  • If both plans cover the claimant as a laid-off or a retired Employee (or a Dependent of such Employee) the plan that covered the Employee for the longest period of time will pay first.

If part of a plan coordinates benefits and a part does not, each part will be treated like a separate plan. The Plan will always pay primary to Medicaid.

Notwithstanding any provision to the contrary, if an Eligible Dependent is covered by another group health plan that reduces or eliminates its benefits when a Dependent is covered by another group health plan, or if the other group health plan has COB provisions that differ from those of this Plan, this Plan will only pay the amount of benefits that would be payable if the other group health plan had the same coordination of benefit provisions as this Plan.