UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS                                   HEALTH and WELFARE FUND

Coordination of Benefits ("COB")

There are special rules for paying claims  if you or your dependents are covered under more than one plan. (For example, these rules will apply if your spouse has 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, since it explains under which plan 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 the other plans. 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 expense, or more than 100 percent of the actual charge. 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 or your dependents are covered under more than one Fund policy. Please, contact the Fund office for details.) Child Care When you use a network child care center, this plan is the primary plan. When you use a non-network center, this plan is always supplemental to all other sources of coverage. If you or your dependents are covered for child care benefits under any other plan, that other plan is the primary plan and this plan is the secondary plan. Educational Benefit Program This plan is always supplemental to all other sources of coverage. If you or your dependents are eligible for tuition benefits under any other plan, that other plan is the primary plan and this plan is the secondary plan. Optional Medical Coverage( Keystone Point of Service) The primary plan is determined by the relationship of the patient to the plan participant. When you, the participant, are the patient, this plan 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. Determine which parent's birthday fails earlier in the year, and file claims to that plan first. For example, assume that your birthday is August 13 and your spouse's birthday is September 28. Since your birthday falls 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. Physical Well-Being Program This plan is always supplemental to all other sources of coverage. If you or your dependents are eligible for physical well-being benefits under any other plan, that other is the primary plan and this plan is the secondary plan. Coordinating With Medicare If you or your dependents are covered for Medicare and you are not retired, this Plan is the primary plan. Medicare is the secondary plan. If you or your spouse is over age 65 and either of you is actively employed by a contributing employer, your benefits remain the same as the benefits of active participants who are under age 65, as described in the paragraph above. If you are no longer employed by a contributing employer, and you or one of your dependents is entitled to Medicare on the basis of disability, Medicare is the primary Plan, except if the disability is based upon end-stage renal disease. If the disability  is based upon end-stage renal disease, the Fund will be primary for 30 month beginning with the first month in month in which the individual receives kidney dialysis and ending on the earlier of the 30th month thereafter or the date the individual receives a kidney transplant.