© 2000-2016 All Rights Reserved, Insurance Design Administrators, Inc
Forms Insurance Design Administrators Home Services Contact Us Customer Service FAQ PPO Links Health Related Websites
Coordination of Benefits Coordination of benefits refers to the set of rules used when two (2) or more plans cover charges incurred by a Covered Person. These rules determine which plan should pay first, then second, etc. These situations arise when a Covered Person is covered by more then one plan, or the Covered Person's Spouse is covered by more then one plan, or the couple's covered Dependent children are covered under two (2) or more plans. The plan that pays first according to the rules will pay as if there were no other plan involved. Benefit Plan This provision will coordinate the health benefits of the plan. The term benefit plan means the Plan covering you or any one (1) of the following plans: 1. Group or group-type plans, including franchise or blanket benefit plans. 2. Blue Cross and Blue Shield group plans. 3. Group practice and other group prepayment plans. 4. Federal government plans or programs. This includes Medicare. 5. Other plans required or provided by law. This does not include Medicaid or any benefit plan           like it that, by its terms, does not allow coordination. 6. No-Fault Auto Insurance, or Out-of-State Automobile Insurance Coverage (OSAIC), by whatever name it is called, when not prohibited by law. Allowable Charge For a charge to be allowable it must be a Usual and Reasonable Charge and at least part of it must be covered under this Plan. In the case of service type plans where services are provided as benefits, the reasonable cash value of each service will be the Allowable Charge. In the case of HMO (Health Maintenance Organization) plans: This Plan will not consider any charges in excess of what an HMO provider has agreed to accept as payment in full. Also, when an HMO is primary and the Covered Person does not use an HMO provider, this Plan will consider as an Allowable Charge any charge that would have been covered by the HMO had the Covered Person used the services of an HMO provider. Benefit Plan Payment Order When two (2) or more plans provide benefits for the same Allowable Charge, benefit payment will follow these rules. 1. Plans that do not have a coordination provision, or one like it, will pay first. Plans with such a provision will be considered after those without one. 2. Plans with a coordination provision will pay their benefits by these rules up to the Allowable Charge. (a) The benefits of the plan which covers the person directly (that is, as an Employee, Member or Subscriber), "Plan A", (that is, other than as a Dependent) are determined before those of the plan which covers the person as a Dependent, "Plan B". Special Rule: As a result of the rules established by Title XVIII of the Social Security Act and implementing regulations, (i) if the person who is covered directly is a Medicare beneficiary, and (ii) Medicare is secondary to the plan covering the person as a Dependent, "Plan B", and (iii) Medicare is primary to the "Plan A" (for example, the person is retired), THEN "Plan B" will pay before "Plan A". (b) The benefits of a benefit plan which covers a person as an Employee who is neither laid-off nor retired are determined before those of a benefit plan which covers that person as a laid-off or Retired Employee. The benefits of a benefit plan which covers a person as a Dependent of an Employee who is neither laid-off nor retired are determined before those of a benefit plan which covers a person as a Dependent of a laid-off or Retired Employee. If the other benefit plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule does not apply. (c) The benefits of a benefit plan which covers a person as an Employee who is neither laid-off nor retired or a Dependent of an Employee who is neither laid-off nor retired are determined before those benefits of a plan which covers the person as a COBRA beneficiary. (d) When a child is covered as a Dependent and the parents are not separated or divorced, these rules will apply: 1. The benefits of the benefit plan of the parent whose birthday falls earlier in a year are determined before those of the benefit plan of the parent whose birthday falls later in that year; 2. If both parents have the same birthday, the benefits of the benefit plan which has covered the parent for the longer time are determined before those of the benefit plan which covers the other parent. (e) When a child's parents are divorced or legally separated, these rules will apply: 1. This rule applies when the parent with custody of the child has not remarried. The benefit plan of the parent with custody will be considered before the benefit plan of the parent without custody. 2. This rule applies when the parent with custody of the child has remarried. The benefit plan of the parent with custody will be considered first. The benefit plan of the stepparent that covers the child as a Dependent will be considered next. The benefit plan of the parent without custody will be considered last. 3. This rule will be in place of items (i) and (ii) above when it applies. A court decree may state which parent is financially responsible for the health benefits of the child. In this case, the benefit plan of that parent will be considered before other plans that cover the child as a Dependent. 4. If the specific terms of the court decree state that the parents shall share joint custody, without stating that one (1) of the parents is responsible for the health care expenses of the child, the plans covering the child shall follow the order of benefit determination rules outlined above when a child is covered as a Dependent and the parents are not separated or divorced. (f) If there is a conflict after these rules have been applied, the benefit plan which has covered the person for the longer time will be considered first. (g) If there is still a conflict in the coordination of benefits and none of the preceding rules determine which plan would be the primary plan, the Allowable Expenses shall be shared equally between the plans. 3. Medicare will pay primary, secondary or last to the extent stated in federal law. When Medicare  is to be the primary payer, this Plan will base its payment upon benefits that would have been paid by Medicare under Parts A and B, regardless of whether or not the person was enrolled under both of these parts. 4. If a Plan Participant is under a disability extension from a previous benefit plan, that benefit plan will pay first and this Plan will pay second. 5. Please review your benefit plan for any other provisions regarding coordination of benefits.