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UFCW LOCAL 1776 and
PARTICIPATING EMPLOYERS HEALTH and WELFARE FUND |
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There are special rules for paying claims if you are covered under more than one plan. (For example, these rules will apply if you are covered under your spouse’s group medical coverage from his or her employer.) These rules determine the order in which bills are submitted and paid by the various plans. They also limit the amount of reimbursement to 100 percent of the covered expenses. Please read this section carefully so that you may identify the plan to which you should submit your claims first. Primary and Secondary Plans A primary plan is a plan whose benefits are determined without taking the existence of any other plan into consideration. A secondary plan is a plan which is not a primary plan. A plan that does not have order of benefit determination rules is always the primary plan. You must first submit your claims and receive payment from the primary plan before any benefits will be paid under the secondary plan. Once you submit your expenses to the primary plan, you may then submit any outstanding balances, along with the Explanation of Benefits or the Statement of Denial from the other plan, to the secondary plan for payment. When you incur a claim, the primary plan pays benefits up to the allowed amount of charges for the covered person without regard to any other secondary plan. If the charges exceed the maximum allowed by the primary plan, you should submit the additional charges to the secondary plan. The secondary plan then adjusts its benefits so that the total benefit paid is not more than the allowable expenses, or more than 100 percent of the actual charges. No plan pays more than the maximum payable under that plan without the coordination of benefits. There are different rules for determining primary and secondary plans for each different benefit. Please read the following sections carefully to determine how to file claims for each benefit. There are special coordination of benefits rules if you are covered under more than one Fund policy. Please contact the Fund office for details.) Dental The primary plan is determined by the relationship of the patient to the plan participant. When you, the participant, are the patient, this is the primary plan and any other plan is the secondary plan. When your spouse is the patient, his/her plan is the primary plan and this plan is the secondary plan. When your child is the patient, follow the “Birthday Rule." Under the “Birthday Rule,” the primary plan is the plan of the parent whose birthday occurs earlier in the year. For example, assume that your birthday is August 13 and your spouse’s birthday is September 28. Since your birthday occurs earlier in the year, this plan is the primary plan for your children. The Fund uses the American Dental Association Guidelines on Coordinating Dental Benefits to determine how payments are to be made. Prescription Drug The primary plan is determined by the relationship of the patient to the plan participant. When you, the participant, are the patient, this is the primary plan and any other plan is the secondary plan. When your spouse is the patient, his/her plan is the primary plan and this plan is the secondary plan. When your child is the patient, follow the “Birthday Rule." Under the “Birthday Rule,” the primary plan is the plan of the parent whose birthday occurs earlier in the year. For example, assume that your birthday is August 13 and your spouse’s birthday is September 28. Since your birthday occurs earlier in the year, this plan is the primary plan for your children. If you and your spouse are separated or divorced, you should file claims first to the plan of the parent who has been assigned financial responsibility by a court decree. If that determination has not been made, the plan of the parent with custody pays before the plan of the other parent. The plan of the step-parent married to the parent with custody of the child pays before the plan of the parent who does not have custody. Prescription Incentive Program This plan is always supplemental to all other sources of coverage. If you are eligible for prescription coverage under any other plan, that other plan is the primary plan and this plan is the secondary plan. Vision Benefit payments are not coordinated with any other plan. Therefore, this plan is the primary plan. |