A. Definitions
"Plan" means a plan which provides benefits or services for, or by reason of, dental care and which is:
1. a group insurance plan; or
2. a group blanket plan, but not including school accident-type coverages covering students in:
a. a grammar school;
b. a high school; or
c. a college; for accident only (including athletic injuries) either on a 24 hour basis or on a "to and from school basis"; or
3. a group practice plan; or
4. a group service plan; or
5. a group prepayment plan; or
6. any other plan which covers people as a group; or
7. a governmental program or coverage required or provided by any law, except Medicaid, but including any motor vehicle No Fault coverage which is required by law.
Each policy, contract or other arrangement for benefits or services will be treated as a separate Plan. Each part of such a Plan which reserves the right to take the benefits or services of other Plans into account to determine its benefits will be treated separately from those parts which do not.
"This Plan" means only those parts of This Plan which provide benefits or services for dental care. The provisions of This Plan which limit benefits based on benefits or services provided under:
1. Government Plans; or
2. Plans which the Policyholder (or an affiliate) contributes to or sponsors; will not be affected by these Coordination of Benefits provisions.
"Primary Plan/Secondary Plan" When This Plan is a Primary Plan, it means that This Plan's benefits are determined:
1. before those of the other Plan; and
2. without considering the other Plan's benefits.
When This Plan is a Secondary Plan, it means that This Plan's benefits:
1. are determined after those of the other Plan; and
2. may be reduced because of the other Plan's benefits.
When there are more than two Plans covering the person, This Plan may be a Primary Plan as to one or more of those other Plans and may be a Secondary Plan as to a different Plan or Plans.
"Allowable Expense" means any reasonable and customary charge which meets all of the following tests:
1. it is a charge for an item of necessary dental expense; and
2. it is an expense which a Covered Person must pay; and
3. it is an expense at least a part of which is covered under at least one of the Plans which covers the person for whom claim is made.
When a Plan provides fixed benefits for specified events or conditions rather than benefits based on expenses, any benefits under that Plan will be deemed to be Allowable Expenses. When a Plan provides benefits in the form of services rather than cash payment, the reasonable cash value of each service rendered will be deemed to be both an Allowable Expense and a
benefit paid.
However, Allowable Expenses do not include:
a. expenses for services rendered because of:
A. an Occupational Sickness; or
B. an Occupational Injury.
b. any amount of benefits reduced under a Primary Plan because the Covered Person does not comply with the Plan provisions. Examples of such provisions are those related to:
1. second surgical opinions;
2. precertification of admissions or services; and
3. preferred provider arrangements.
Only benefit reductions based upon provisions similar in purpose to those described in the prior sentence and which are contained in the Primary Plan may be excluded from Allowable Expenses. This provision will not be used by a Secondary Plan to refuse to pay benefits because a Health Maintenance Organization member has elected to have health care services provided by a non-HMO provider and the HMO, pursuant to its contract, is not obliged to pay for providing those services.
"Claim Determination Period" means a period which starts on any January 1 and ends on the next December 31. However, a Claim Determination Period for any Covered Person will not include periods of time during which that person is not covered under This Plan.
"Custodial Parent" means a parent awarded custody by a court decree. In the absence of a court decree, it is the parent with whom the child resides more than half of the calendar year without regard to any temporary visitation.
B. Effect on Benefits
1. When there is a basis for a claim under This Plan and another Plan, This Plan is a Secondary Plan which has its benefits determined after those of the other Plan, unless:
a. the other Plan has rules coordinating its benefits with those of This Plan; and
b. both those rules and This Plan's rules in subsection 3 of this Section B require that This Plan's benefits be determined before those of the other Plan.
2. If This Plan is a Secondary Plan, when the total Allowable Expenses incurred for a Covered Person in any Claim Determination Period are less than the sum of:
a. the benefits that would be payable under This Plan without applying this Coordination of Benefits provision; and
b. the benefits that would be payable under all other Plans without applying Coordination of Benefits or similar provisions; the benefits described in item 2(a) of this section B will be reduced. The sum of these reduced benefits plus all benefits payable for such Allowable Expenses under all other Plans will not exceed the total of the Allowable Expenses. Benefits payable under all other Plans include all benefits that would be payable if the proper claims had been given on time.
When the benefits of This Plan are reduced as described above, each benefit is reduced in proportion. It is then charged against the benefit limits of This Plan.
3. Rules for Determining the Order in which Plans Determine Benefits. When more than one Plan covers the person for whom Allowable Expenses were incurred, the order of benefit determination is:
a. Non-dependent/Dependent. The Plan which covers that person other than as a dependent (for example, as a member, member, subscriber or retiree) determines its benefits before the Plan which covers that person as a dependent; except that if the person is also a Medicare beneficiary, and as a result of the rules established by Title XVIII of the Social Security Act and implementing regulations, Medicare is:
i. Secondary to the Plan covering the person as a dependent; and
ii. Primary to the Plan covering the person as other than a dependent (e.g., a retired person); then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering that person as other than a dependent.
b. Child Covered under More than One Plan. When This Plan and another Plan cover the same child as a dependent of different persons, called "parents":
i. the Primary Plan is the Plan of the parent whose birthday is earlier in the year if:
1. the parents are married; the parents are not separated (whether or not they ever have been married); or
2. a court decree awards joint custody without specifying that one party is responsible for providing health care coverage.
c. For example, if one parent's birthday were January 8 and the other parent's birthday were March 3, then the Plan covering the parent with the January 8 birthday would determine its benefits before the Plan covering the parent with the March 3 birthday.
i. if both parents have the same date of birth (excluding year of birth), the Plan which covered the parent for the longer time determines its benefits before the Plan which covered the other parent for the shorter time.
ii. if the specific terms of a court decree state that one of the parents is responsible for the child's healthcare expenses or healthcare coverage and the Plan of that parent has actual knowledge of those terms, that Plan is Primary. This paragraph does not apply with respect to any Claim Determination Period during which any benefits are actually paid or provided before that Plan has that actual knowledge of the terms of the court decree.
iii. if the parents are not married or are separated (whether or not they have ever been married) or are divorced, the order of benefits is:
1. the Plan of the Custodial Parent;
2. the Plan of the spouse of the Custodial Parent;
3. the Plan of the Non-Custodial Parent;
4. the Plan of the spouse of the Non-Custodial Parent.
c. Active/Laid-off or Retired Member. The Plan which covers that person as an active member (or as that member's dependent) is Primary to a Plan which covers that person as a laid-off or retired member (or as that member's dependent). If the Plan which covers that person has not adopted this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule shall not apply.
d. Continuation Coverage. The Plan which covers the person as an active member, member or subscriber (or as that member's dependent) is Primary to a Plan which covers that person under a right of continuation pursuant to federal law (e.g., COBRA) or state law. If the Plan which covers that person has not adopted this rule, and if, as a result, the Plans do not agree on the order of benefits, this ruled. shall not apply.
e. Longer/Shorter Time Covered. If none of the above rules determines the order of benefits, the Plan which has covered the Member for the longer time determines its benefits before the Plan which covered that person for the shorter time.
C. Right to Receive and Release Needed Information
Certain facts are needed to apply these Coordination of Benefits rules. We have the right to decide which facts we need. We may get facts from or give them to any other organization or person. We need not tell, nor get the consent of, any person or organization to do this. To obtain all benefits available, a claim should be filed under each Plan which covers the person for whom Allowable Expenses were incurred. Each person claiming benefits under This Plan must give us any facts we need to pay the claim.
D. Facility of Payment
A payment made under another Plan may include an amount which should have been paid under This Plan. If it does, we may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under This Plan. We will not have to pay that amount again. The term "payment made" includes providing benefits in the form of services, in which case "payment made" means reasonable cash value of the benefits provided in the form of services.
E. Right of Recovery
If the amount of the payments made by us is more than we should have paid under this Coordination of Benefits provision, we may recover the excess from one or more of:
1. the persons we have paid or for whom we have paid;
2. insurance companies; or
3. other organizations.
The "amount of the payment made" includes the reasonable cash value of any benefits provided in the form of services.