Effect Of Benefits Under Other Plans: Coordination Of Benefits

Definitions

The following definitions generally apply to the coordination of benefits provision outlined here...

Any group insurance or group-type blanket coverage, whether insured or uninsured, that provides benefits or services for, or because of, health care or treatment. This includes prepayment, group practice or individual practice coverage, and service plan contracts. It does not include school accident type coverage.

Each contract or other coverage arrangement is considered a separate plan, and if an arrangement has two parts, each of the two parts is a separate plan.

Refers to the part of this (the A&B FlexSolutions) benefit program that provides the benefits for health care expenses.

Refers to the plan whose benefits will be determined before those of the other plan are considered. Benefits under the primary plan will not be reduced due to benefits payable under other plans.

Refers to the plan whose benefits will be determined after the benefits of the primary plan are considered. When this Plan is the secondary plan, the benefits of this Plan may be reduced. Note: When there are more than two plans covering an individual, this Plan may be primary in some circumstances and secondary in other circumstances.

A health care expense item that is covered at least in part by one or more plans covering the individual for whom the claim is made. The difference between the cost of a private hospital room and the semi-private hospital room is not considered an allowable expense under this definition, unless the covered individual's stay in a private hospital room is medically necessary as a generally accepted medical practice.

When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered both an allowable expense and a benefit paid.

A calendar year. However, it does not include any part of a year during which an individual has no coverage under this Plan, or before the date of this provision or a similar provision.

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How Benefit Payment Is Determined

The order in which the plans will pay benefits will be determined as follows, using the first rule that applies:

1. A plan with no rules for coordination with other benefits will be deemed to pay its benefits before a plan that contains such rules.

2. A plan that covers the individual as an employee will be deemed to pay benefits before a plan that covers the same individual as a dependent. (An individual may be covered as a dependent under two or more plans. Special provisions apply if the individual is a Medicare beneficiary as outlined under Effect Of Medicare.)

3. Except in the case of a dependent child whose parents are divorced or separated: the benefits of the plan of the parent whose birthday falls earlier in the year are determined first. If both parents have the same birthday, the benefits of the plan that covered either parent longer are determined before those of the other plan. However, if the other plan does not have this rule, but instead has another rule, the rule in the other plan will determine which plan is primary.

4. In the case of a dependent child whose parents are divorced or separated, the determination of which plan is primary and which plan is secondary will be based on the following: If there is...

   • A court decree that states the parents must share joint custody of a dependent child, without stating that one of the parents is responsible for the health care expenses of the child, the rules outlined in #3 above will apply.

   • A court decree that establishes financial responsibility for the health care expenses with respect to the dependent child, the benefits of the plan that covers the child as a dependent of the parent with such financial responsibility will be determined before the benefits of any other plan that covers the child as a dependent child.

   • No court decree, the plan of the parent with custody will be primary to a plan of the parent without custody. If the parent with custody has remarried, the plan of the:

     • parent with custody will pay benefits first, then

     • spouse/domestic partner of the parent with custody will pay benefits next, then

     • parent without custody will pay benefits next.

5. The benefits of a plan that covers the individual as an active employee (or a dependent of an active employee) are determined before those of a plan covering that individual as a laid-off or retired employee (or as a dependent of a laid-of or retired employee). However, if both plans do not have this rule and if, as a result, the plans do not agree on the order of benefits, this rule will not apply.

6. The benefits of a plan covering the individual as an active employee (or a dependent of that employee) pays before the plan that covers the same individual as a COBRA beneficiary or retired employee.

7. If none of the above rules determine the order of benefits, the plan covering the individual for the longest time will be primary to all other plans. An exception to this rule is that when the coordination of benefits rules of this Plan and any other plan both agree that this Plan is primary, the benefits of the other plan will be disregarded in applying this rule.

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How Your Benefits May Be Affected

The general rule that applies under this provision is that the benefits otherwise payable under this Plan for all allowable expenses incurred in a calendar year will be reduced by the total benefits payable under all "other plans" for the same expenses.

This means that, for each eligible expense, the secondary plan will only pay benefits to make up any difference between the...

• Amount payable under the other plans, and

• Total amount of the eligible expenses incurred.

Here's how the coordination of benefits provision would work if your spouse had medical coverage through his or her employer and was also enrolled in a FlexSolutions Medical Plan. For the purposes of this illustration, assume the following...

• You and your spouse are enrolled in the CIGNA PPO Plan.

• Your spouse has already satisfied both plans' deductibles, and incurs $1,000 in eligible hospitalization expenses.

• Both plans pay 90% of the eligible charges for hospitalization.

Because your spouse's plan is "primary," your spouse is reimbursed 90%, or $900, under that plan. Then, your spouse submits a claim for the unreimbursed expenses under the FlexSolutions CIGNA PPO Plan. While the CIGNA PPO Plan would have paid $900 if your spouse had no other coverage, the Plan will only pay $100—the difference between the total expense and the amount the other plan paid ($1,000 - $900 = $100).

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Right To Receive Needed Information

Certain facts are needed to apply the rules of this provision. The Claims Administrator has the right to decide which facts are necessary and may release to, or obtain from, any insurance company or individual any necessary information with respect to any covered individual. Each individual claiming benefits under this Plan must give the Claims Administrator any facts it needs to coordinate and pay the claim.

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Medicare Enrollment Requirements

When this Plan is primary (without regard to Medicare) and you want Medicare to be secondary, you (or your Medicare-eligible dependent) must enroll in Medicare Parts A and B. If you (or your dependent) do not enroll in Medicare when you first become eligible, you must enroll during the special enrollment period that will apply when you are no longer eligible under this Plan.

When Medicare is primary, benefits available under Medicare will be deducted from the amount payable under this Plan—even if you have not enrolled in Medicare. Therefore, if Medicare is primary, you (or your dependent) should enroll for both Parts A and B of Medicare when you are eligible; otherwise, you may not receive benefits from either this Plan or Medicare. Note that HMSA will not apply this provision if the covered individual is not enrolled in Medicare.

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Benefit Payments

If you (or a dependent) become eligible under Medicare and Medicare is the primary payer of benefits, this Plan will pay benefits as outlined below:

First, this Plan determines the amount payable according to the benefits under the Plan. However the amount of covered expenses is based on the amount of charges allowed under Medicare, not the amount allowed under the provisions of this Plan. Then, this Plan subtracts the amount payable under Medicare for the same expenses from Plan benefits. This Plan pays only the difference (if any) between Plan benefits and Medicare benefits.

The amount payable under Medicare that is subtracted from this Plan's benefits is determined as the amount that would have been payable under Medicare when Medicare is primary even if the covered individual...

• Is not enrolled for Medicare; Medicare benefits are determined as if the individual were covered under Medicare Parts A and B (HMSA will not apply this provision if the covered individual is not enrolled in Medicare);

• Is enrolled in a Medicare+Choice (Medicare Part C) plan and receives non-covered out-of-network services because the individual did not follow all rules of that plan—Medicare benefits are determined as if the services were covered under Medicare Parts A and B (HMSA will not apply this provision);

• Receives services from a provider who has elected to opt-out of Medicare—Medicare benefits are determined as if the services were covered under Medicare parts A and B, and the  provider had agreed to limit charges to the amount of charges allowed under Medicare rules (HMSA will not apply this provision);

• Received services from a Veterans Administration facility or any other facility of the federal government—Medicare benefits are determined as if the services were provided by a non-governmental facility and covered under Medicare; or

• Is enrolled in a Plan with a Medicare Medical Savings Account —Medicare benefits are determined as if the individual were covered under Medicare Parts A and B (HMSA will not apply this provision).

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