When You Have Other Medical Insurance

Download (0)

Full text


When You Have Other Medical Insurance

Coordination of Benefits (COB)

The COB provision applies to this Plan when a Covered Person has health care coverage under more than one health plan.

All of the medical expense benefits provided by the policy are subject to this provision. Definitions

Plan means any arrangement of coverage written on an expense incurred basis, which provides medical benefits or services by means of:

1. Group or blanket coverage, whether insured or uninsured including coverage provided through:

a. HMO's and other prepayment group or individual practice plans; b. Mandatory automobile "no fault" and "fault" insurance, including individual insurance.

2. Governmental programs, except:

a. Coverage provided under Title XVIII (Medicare) and Title XIX (Medicaid) of the Social Security Act of 1965, as amended; and b. Any Plan when by law its benefits are excess to those of any private insurance Plan or non-governmental Plan.

3. Any coverage under:

a. Labor-management trusteed plans; b. Union welfare plans;

c. Employer organization plans or employee benefit organization plans.

Plan does not mean:

1. Any type of school accident coverage, including college plans; or 2. Individual or family plans or contracts, where the policyholder pays the premium

This Plan means the SWSCHP Plan.

Primary means a Plan which pays Allowable Expenses without regard to the existence of any other Plans.


Secondary means any Plan which is not considered the Primary Plan. When there are more than two Plans covering the same Covered Person, this Plan may be Primary as to one or more Plans, and Secondary as to a different Plan or Plans.

Allowable Expense(s) means any expense incurred by a Covered Person which is:


For a Necessary Service or Supply; and

Covered in part at least by one or more Plans which insure the Covered Person The difference between the cost of a private hospital room, and a semi-private hospital room, is not considered an allowable expense unless the patient's stay in the private hospital room is medically necessary.

In the case of Health Maintenance Organization (HMO) Plans, This Plan will not consider any charges in excess of what an HMO provider has agreed to accept as payment in full. When a Plan provides benefits in the form of services, rather than cash payments, the reasonable value of each service rendered will be considered both an Allowable Expense and a benefit paid.

Payment in Accordance With This Plan means payment will be made to either the Employee/Member; or to the Doctor; or other provider that rendered the service to the Member. This payment satisfies the Plan's obligation for payment.

Claim Determination Period means a Calendar Year, or portion thereof, during which a Covered Person is covered by This Plan.

When this COB Provision Applies

1. A Covered Person is covered under SWSCHP and one or more other health plans

2. The Covered Person incurs Allowable Expense during a Claim Determination Period

3. The sum of the benefits payable under all of the health plans, in the absence of this or a similar provision, is more than those benefits which a person could have collected, but for which they did not apply

How this COB is Applied

The SWSCHP Plan Administrator will determine which Plan is Primary and which Plan is Secondary. In order to obtain all benefits available, a Covered Person should file a claim under each health plan.

1. When SWSCHP is primary

a. The Plan will pay its benefits without regard to the existence of any other health plan.


2. When SWSCHP is secondary

a. The Plan will pay a reduced benefit, which when added to the benefit paid by all other health plans, will not exceed 100% of the total Allowable Expense. No Plan will pay more than it would have paid in the absence of this provision.

b. When SWSCHP is secondary, any benefits reduced during any Claim Determination Period because of this provision, will be reduced proportionately. Only the reduced amount may be charged against any benefit limit of SWSCHP.

Order of Benefits Determination

A health plan will always be Primary and will pay its benefits first if the Plan has no Order of Benefits Determination rules, or it has rules which differ from those set forth here.

Otherwise, the Primary and the Secondary Plan will be determined according to the following rules:

1. You are the Insured Person under the SWSCHP Plan and the Covered Dependent under a second health plan

a. SWSCHP is your primary coverage. b. All other health plans are secondary.

2. A child is covered as a Dependent under the SWSCHP Plan and the parents are not separated or divorced

a. The benefits of the health plan of the parent whose birthday falls earlier in a year are primary; the health plan of the other parent is secondary.

b. If both parents share the same birthday, the health plan which has covered a parent for the longer period of time is primary, the plan with the lesser longevity is secondary.

c. If the child is covered by SWSCHP and an additional plan, and the additional plan does not have the rule described immediately above, but instead has a rule based upon the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the additional plan will determine which plan is Primary and which is Secondary.

3. A child is covered as a Dependent under the SWSCHP Plan and the parents are divorced or separated

a. If the parent with custody of the child has not remarried, the health plan of the parent with custody is Primary; the health plan of the parent without custody is Secondary.


b. If the parent with custody has remarried, the health plan of the parent with custody is Primary, the benefit plan of the stepparent that covers the child as a Dependent is Secondary and the health plan of the parent without custody is Tertiary.

c. If a court decree has stated which parent is financially responsible for medical and dental benefits of the child, the benefit plan of that parent will be considered Primary over other plans that cover the child as a Dependent.

4. The benefits of a Plan which covers an employed person as an Insured Person or a Covered Dependent of that Insured Person is Primary, health plans of retired or laid off Insured Persons and their Covered Dependents are


If there is still a conflict after these rules have been applied, the benefit plan which has covered the patient longer will be considered Primary.

When You Have Medicare Coverage

There are times when Federal Law determines whether this Plan or Medicare will pay its benefits first. When you are eligible for Medicare, the benefits under this Plan may change; how they change will depend on your age and whether you are a Retired Employee, an Active Employee, a Dependent or are Disabled. You will be considered Disabled if you are eligible for Medicare due to your disability.

Retired Employees and/or their Dependents: If you are eligible and enroll for Medicare, your covered Medical Expenses will be reduced by the amount paid by Medicare and the

balance considered for payment, subject to Deductible and Coinsurance.

If a Retired Employee or a Retired Employee's Dependent does not elect to sign up for Part A and Part B of Medicare benefits, it will severely reduce the amounts paid for medical services rendered. The Plan will pay as thought the Employee does have Medicare as his primary coverage, and all balances will be the responsibility of the Employee. Therefore, it is essential that each eligible Retiree and Retiree's Dependent be enrolled in both parts of Medicare.

Order of Benefits for Retired Employees

A retired contract is always secondary to an active contract.

The only way you can choose Medicare as the Primary Payor is by canceling this Plan. If you do so, there will be no further coverage available for you under this Plan. 1. You are retired from your school district, carry SWSCHP Health Insurance

and work elsewhere with health benefits a. Your employer's coverage is primary. b. SWSCHP is secondary.


2. You are retired from your school district, carry SWSCHP Health Insurance and are also covered under your working spouse's health insurance plan

a. Your spouse's plan is primary. b. SWSCHP is secondary.

3. You are retired, have Medicare and SWSCHP coverage and your working spouse covers you under his/her health insurance plan

a. Your spouse's plan is primary. b. Medicare is secondary.

c. SWSCHP is tertiary.

4. You and your spouse are both retired and not eligible for Medicare. You carry SWSCHP Health Insurance and your spouse carries his/her own health


a. You are primary to SWSCHP.

b. Your spouse is primary to his/her own health insurance. c. If either or both of you carry family plans, you may each be secondary to each other's plan.

5. You and your spouse are both retired and have Medicare. One of you carries SWSCHP and the other carries his/her own health insurance

a. You are primary to Medicare, secondary to SWSCHP and tertiary to your spouse's plan.

b. Your spouse is primary to Medicare, secondary to his/her own health insurance and tertiary to SWSCHP.

c. In the event that you or your spouse do not have family coverage through SWSCHP or any other carrier, both of you are primary to Medicare and secondary to your own plans.

6. You and your spouse are both retired. You carry SWSCHP and have Medicare but your spouse is not eligible for Medicare

a. You are primary to Medicare and Secondary to SWSCHP b. Your spouse is Primary to SWSCHP

7. You and/or your spouse are Disabled.


a. You may be eligible for Medicare in accordance with the provisions of the Social Security Act. During any period in which Medicare is the Primary Payor, your covered medical expenses will be limited to that part of such expenses of which benefits are not available in any form under the Act, as evidenced by a statement to the effect from the Social Secuirity Administration.

8. Your and/or your spouse have End Stage Renal Disease:

a. You and your spouse are primary to SWSCHP during the first 30 months of treatment for end-stage renal failure.

b. After this initial 30 month period, Medicare will pay first. Right to Receive and Release Necessary Information

For the purpose of this provision, the Plan Administrator has the right to give information to, or obtain information from:

Any other insurance company;

Any organization;

Or any person;

regarding you or your Dependents. As a claimant under This Plan, you must supply the Plan Administrator with information necessary to enforce this provision unless prohibited under Article 25 of the New York General Business Law.

Facility of Payment

When another Plan makes payments which should have been made under This Plan, the Plan Administrator reserves the right to decide:

Whether or not to reimburse the organization making the payment; and

The amount to be paid in order to satisfy the intent of this provision

Any such payment made by the Plan Administrator will fulfill This Plan's responsibility in the amount paid.

Right of Recovery

This Plan may pay benefits that should be paid by another benefit plan. In this case, This Plan may recover the amount paid from:

Any other insurance company;

Any other organization; or

The person to or for whom the benefits were paid

Further, this Plan may pay benefits that are later found to be greater than the allowable charge. In this case, this Plan may recover the amount of the overpayment from the source to which it was paid.

On occasion, a payment will be made when you are not covered under this Plan, or for a


service which is not covered, or in an amount which is more than proper. When this happens, the problem will be explained to you, and your must return the amount of the overpayment within 60 days.

Assignment of Benefits

You cannot assign any right for benefits or monies due under this Plan to any person, corporation or other organization. Any such assignment by you will be void. Assignment means the transfer to another person, corporation or organization of your right to the benefits or payment under this Plan, or your right to collect money from this Plan for those services.

Third Party Recovery Provision - Right of Refund

The Covered Person may incur medical charges due to injuries for which benefits are paid by the Plan. The Injuries may be caused by the act of or omission of a third party. If so, the Covered Person may have a claim against the third party for payment of the medical charges.

Amount subject to refund - Only the amount recovered for medical charges will be subject to refund. In no case will the amount of refund exceed the amount of medical benefits paid for the Injury under the Plan.

Defined Terms:

Recovery - monies paid to the Covered Person through judgment, settlement, or otherwise to compensate for all losses caused by the injuries

Refund - repayment to the Plan for all benefits paid

Recovery from Another Insurer of the Covered Person - This Right of Refund also applies when a Covered Person recovers under an uninsured or underinsured motorist plan. The Covered Person must cooperate fully with the Plan in asserting their right to recover.




Related subjects :