Administrative Information and General Provisions
Duplicate Coverage - Duplicate coverage is the term used to describe when you are covered by this coverage and
also covered by another:
Group or group-type health insurance; Health benefits coverage; or
Blanket coverage.
The total benefits received by you, or on your behalf, from all coverage’s combined for any claim for Covered Services will not exceed 100 percent of the total covered charges.
Allowable Expense is a health care expense, including Deductibles, Coinsurance and Copayments, that is covered at least in part by any plan covering you. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense that is not covered by any plan covering you is not an allowable expense. In addition, any expense that a Provider by law or in accordance with a contractual agreement is prohibited from charging you is not an allowable expense.
The following are not Allowable Expense:
1. The difference between the cost of a semi-private hospital room and a private hospital room, unless one of the plans provides coverage for private hospital room expenses.
2. If you are covered by two plans that calculate benefits or services on the basis of a reasonable and customary amount or relative value schedule reimbursement method or some other similar reimbursement method, any amount in excess of the higher of the reasonable and customary amounts.
3. If you are covered by two plans that provide benefits or services on the basis of negotiated rates or fees, an amount in excess of the highest of the negotiated rates.
4. If you are covered by one plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology and another plan that provides its benefits or services on the basis of negotiated fees, the primary plan’s payment arrangement shall be the Allowable expense for all plans. However, if the Provider has contracted with the Secondary plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the primary plan’s payment arrangement and if the Provider’s contract permits, the negotiated fee or payment shall be the Allowable expense used by the secondary plan to determine its benefits.
5. The amount of any benefit reduction by the primary plan because you failed to comply with the Plan provisions is not an allowable expense. Examples of these types of plan provisions include second surgical opinions, pre-certification of admissions, and preferred provider arrangements.
6. If you advise us that all plans covering you are high deductible health plans as defined by Section 223 of the Internal Revenue Code, and you intend to contribute to a health savings account established in accordance with Section 223 of the Internal Revenue Code, any amount that is subject to the primary high deductible health plan’s deductible.
Order of Benefit Determination Rules – The following rules are used in the order as listed:
How We Determine Which Coverage is Primary and Which is Secondary - We will determine the primary
coverage and secondary coverage according to the following rule: A plan that does not have order of benefit determination rules will always be primary unless the provisions of both plans state that the plan is primary.
Non-Dependent or Dependent
The plan that covers the person other than as a dependent, for example as an employee, member, subscriber or retiree, is primary and the plan that covers the person, as a dependent, is secondary. If the person is a Medicare
Administrative Information and General Provisions
beneficiary, please refer to the section below of “Determining Primacy Between Medicare and Us” for primary and secondary payer rules.
Active Employee, Retired or Laid-Off Employee
a. The plan that covers a person as an active employee, who is not laid off or retired, or a dependent of an active employee, is the primary plan.
b. If the secondary, or other plan, does not have this rule, and as result the plans do not agree on the order of benefits, this rule is ignored.
c. This rule does not apply if the section above of “Non-Dependent or Dependent” can determine the order of benefits.
COBRA or State Continuation Coverage
a. If a person whose coverage is provided in accordance with COBRA, or under a right of continuation according to state or federal law is covered under another plan, the plan covering the person as an employee, member, subscriber or retiree or covering the person as a dependent of an employee, member, subscriber, or retiree, is the primary plan and the plan covering that same person in accordance with COBRA, or under a right of continuation in accordance with state or other federal law, is the secondary plan.
b. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule is ignored.
c. This rule does not apply if the section above of “Non-Dependent or Dependent” can determine the order of benefits.
Longer or Shorter Length of Coverage
a. If the rules above do not determine the order of benefits, the plan that covered the person for the longer period of time is primary plan and the plan that covered the person for the shorter period of time is the secondary plan. b. To determine the length of time a person has been covered under a plan, two (2) successive plans will be treated
as one if the covered person was eligible under the second within twenty-four (24) hours after the first ended. c. The start of a new plan does not include:
(1) A change in the amount or scope of a plan’s benefits;
(2) A change in the entity that pays, provides or administers the plan’s benefits; or
(3) A change from one type of plan to another (such as, from a single employer plan to that of a multiple employer plan).
d. The person’s length of time covered under a plan is measured from the person’s first date of coverage under that plan. If that date is not readily available for a group plan, the date the person first became a member of the group will be used as the date from which to determine the length of time the person’s coverage under the present plan has been in force.
If none of the rules above determine the primary plan, the Allowable Expenses will be shared equally between the plans.
Dependent Child Covered Under More Than One Plan
Unless there is a court decree stating otherwise, plans covering a dependent child will determine the order of benefits as follows:
Administrative Information and General Provisions
(1) The plan of the parent whose birthday falls earlier in the calendar year, by month and day, is the primary plan; or
(2) If both parents have the same birthday, the plan that has covered the parent the longest is the primary plan. b. For a dependent child whose parents are divorced or separated or are not living together, whether or not they
have ever been married:
(1) If the court decree states that one of the parents is responsible for the dependent child’s health care expenses or health care coverage, and the plan of that parent has actual knowledge of those terms, that plan is primary. If the parent with financial responsibility has no health care coverage for the dependent child’s health care, but that parent’s spouse does, the spouse’s plan is primary. This item will not apply with respect to a plan year during which benefits are paid or provided before the entity has actual knowledge of the court decree provision;
(2) If the court decree states that both parents are responsible for the dependent child’s health care expenses or health care coverage, paragraph a. above will determine the order of benefits;
(3) If the divorce decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the depend child, paragraph a above will determine the order of benefits; or
(4) If there is no court decree allocating responsibility for the child’s health care expenses of health care coverage, the order of benefits for the child are as follows:
(a) The plan of the custodial parent;
(b) The plan of the spouse of the custodial parent; (c) The plan of the noncustodial parent; and then (d) The plan of the spouse of the noncustodial parent.
c. For a dependent child covered under more than one plan of individuals who are not parents of the child, the order of benefits will be determined, as applicable, according to paragraph a. or b. above as if those individuals were the parents of the child.
d. For a dependent child who has coverage under either or both parents' plans and also has his or her own coverage as a dependent under a spouse's plan, the rule in the section above for “Longer or Shorter Length of Coverage” applies.
In the event the dependent child's coverage under the spouse's plan began on the same date as the dependent child's coverage under either or both parents' plans, the order of benefits will be determined by applying the birthday rule to the dependent child's parent(s) and the dependent's spouse.
Rules for Coordination of Benefits
When a person is covered by two (2) or more plans, the rules for determining the order of benefit payments are as follows:
1. The primary plan must pay or provide its benefits as if the secondary plan or plans did not exist.
2. If the primary plan is a Closed Panel Plan, and the secondary plan is not a Closed Panel Plan, the secondary plan will pay or provide benefits as if it were the primary plan when a covered person uses a non-panel provider, except for emergency services or authorized referrals that are paid or provided by the primary provider.
3. When multiple contracts providing coordinated coverage are treated as a single plan, this section only applies to the plan as a whole, and coordination among the component contracts is governed by the terms of the contracts.
Administrative Information and General Provisions
4. If a person is covered by more than one secondary plan, each secondary plan will take into consideration the benefits of the primary plan, or plans, and the benefits of any other plan, which, has its benefits determined before those of that secondary plan.
5. Under the terms of a Closed Panel Plan, benefits are not payable if the covered person does not use the services of a closed panel provider, with the exceptions of medical emergencies and if there are allowable benefits available. In most instances, Coordination of Benefits does not occur if a covered person is enrolled in two (2) or more Closed Panel Plans and obtains services from a provider in one of the Closed Panel Plans because the other Closed Panel Plan (the one whose providers were not used) has no liability. However, Coordination of Benefits may occur during the claim determination period when the covered person receives emergency services that would have been covered by both plans.
Determining Primacy Between Medicare and Us - We will be the primary payer for persons with Medicare age
65 and older if the policyholder is actively working for an employer who is providing the policy holder’s health insurance and the employer has 20 or more employees. Medicare will be the primary payer for persons with Medicare age 65 and older if the policyholder is not actively working, and the Member is enrolled in Medicare. Medicare will be the primary payer for persons with Medicare age 65 and older if the employer has less than 20 employees and the Member is enrolled in Medicare.
We will be the primary payer for persons enrolled with Medicare under age 65 when Medicare coverage is due to disability if the policyholder is actively working for an employer who is providing the policyholder’s health insurance and the employer has 100 or more employees. Medicare will be the primary payer for persons enrolled in Medicare due to disability if the policyholder is not actively working or the employer has less than 100 employees. We will be the primary payer for persons with Medicare under age 65 when Medicare coverage is due to End Stage Renal Disease (ESRD), for the first 30 months from the entitlement to or eligibility for Medicare (whether or not Medicare is taken at that time). After 30 months, Medicare will become the primary payer if Medicare is in effect (30-month coordination period).
When a Member becomes eligible for Medicare due to a second entitlement (such as age), We remain primary. But this will only apply if the group health coverage was primary at the point when the second entitlement took effect, for the duration of 30 months after becoming Medicare entitled or eligible due to ESRD. If Medicare was primary at the point of the second entitlement, then Medicare remains primary. There will be no 30-month coordination period for ESRD.
Members with Medicare and Two Group Insurance Policies - Based on the primacy rules, if Medicare is
secondary to a group coverage (see Medicare primacy rules), the primary coverage covering the Member will pay first. Medicare will then pay second, and the coverage covering the Member as a retiree or inactive employee or Dependent will pay third. The order of primacy is not based on the policyholder of the group health insurance. If Medicare is the primary payer due to Medicare primacy rules, then the rules of primacy for employees and their spouses will be used to determine the coverage that will pay second and third.
Your Obligations - You have an obligation to provide Us with current and accurate information regarding the
existence of other coverage.
Benefits payable under another coverage include benefits that would be paid by that coverage, whether or not a claim is made. It also includes benefits that would have been paid but were refused. This is due to the claim not being sent to the Provider of other coverage on a timely basis.
Your benefits under this Booklet will be reduced by the amount that such benefits would duplicate benefits payable under the primary coverage.
Out Rights to Receive and Release Necessary Information – We may release to, or obtain, from any insurance
Administrative Information and General Provisions
Payment of Benefits to Others - When payments that should have been made under this Booklet were made under any
other coverage, We will have the right to pay to the other coverage any amount We determine to be warranted to satisfy the intent of this provision. Any amount so paid will be considered to be benefits paid under this Booklet, and with that payment We will fully satisfy Our liability under this provision.
Duplicate Coverage and Coordination of Benefits Overpayment Recovery - If We have overpaid for Covered
Services under this provision, We will have the right, by offset or otherwise, to recover the excess amount from you or any person or entity to which, or in whose behalf, the payments were made.