Health and Welfare Summary Plan Description

• Health and Welfare SPD / Article VIII / Self-Funded PPO Option >>

8.12 Coordination of Benefits

1. General Rules. A Covered Individual may be covered by another group health plan or prescription drug card program in addition to this Plan, potentially resulting in both plans paying on the same claim. This section contains rules for the coordination of benefits. If a Covered Individual is covered under another group plan, the total amount to be paid from all plans will not exceed 100% of the amount of Covered Charges. This section does not apply to non-group (i.e., individual) insurance coverage under which a Covered Individual may be covered. The Plan may obtain or release any information necessary to implement this subsection. You must declare your coverage under other group plans. The Plan can pay to another paying organization amounts warranted to satisfy the intent of this section and, to the extent of such payment, be discharged from liability for that claim. The Plan can also recover amounts that are overpaid under this section from you from any insurer or other organization. Information necessary to the administration of this provision will be required of you at the time a claim is submitted. Payment of the claim may be delayed if the required information is not provided.
   
   
2. Which Plan Pays First When You Are Covered Under More Than One Group Plan
   1. If the other plan has a coordination of benefit provision, the plan that provides health care coverage (i.e., medical, hospital, prescription drug, vision and/or dental) to you as an employee, former employee, or retiree (and not as a dependent) pays first.
   2. If you are covered as an employee or retiree under both health plans, the plan that has provided health care coverage to you longer is the primary payer.
   3. If you are covered as a current or active employee under one plan and a former employee under the other plan, the plan that covers you as an active employee will be the primary payer.
   4. If the other plan has no coordination of benefits provision, that plan is the primary payer.
   5. If a Child is covered under another plan, the plan of the parent whose birthday occurs earlier in the year is the primary payer. However, if the parents are divorced or are separated, the plan of the custodial parent is the primary payer. If joint custody applies, the plan of the parent whose birthday occurs earlier in the year is the primary payer. If the parent with custody remarries, the order of payment is as follows:
      1. natural parent with whom Child resides;
      2. step-parent with whom Child resides; then
      3. natural parent not having custody of the Child.
      This order of payment can change if the child support order directs one of the parents to be financially responsible for the medical, dental or other health care expenses of the Child.
3. Which Plan Pays First When You Are Medicare Eligible
   1. If you are covered as an Active Employee who has attained age 65 and are eligible for Medicare, coverage under the Plan is generally the primary payer. When the Plan is the primary payer, the Plan will pay first and Medicare second. You or your Dependent may, however, elect Medicare as primary. If Medicare is elected as the primary payer, your or your Dependent's coverage under the Plan will cease.
   2. If you are a Medicare eligible Retiree or former employee who has attained age 65, Medicare will be primary and the Plan will be secondary. See Section 8.6(e) for information on how the Plan adjudicates claims for Medicare eligible Retirees and Dependents.
   3. If you are a Medicare eligible Retiree or former employee who has attained age 65 and are covered in another plan as an employee, the plan that covers you as an employee will be primary. The order of payment is as follows:
      1. The Plan in which you are enrolled as an employee
      2. Medicare
      3. The SFEW (Retiree) Plan
   4. If you are a Medicare eligible Retiree or former employee who has attained age 65 and are covered in another plan as a dependent of an active employee, the plan that covers you as a dependent of an active employee will be primary. The order of payment is as follows:
      1. The Plan in which you are enrolled as an employee
      2. Medicare
      3. The SFEW (Retiree) Plan
      If you or your Dependent are entitled to Medicare benefits before age 65 due to total disability or ESRD, the Plan will be the primary payer during any waiting period for Medicare benefits due to total disability or ESRD. After the Medicare waiting period, and you or your Dependent are entitled to Medicare benefits, the Plan will be the secondary payer; provided, however, that the Plan will be the primary payer if you are receiving Active Coverage and you or your Dependent are entitled to Medicare benefits due to total disability for other than ESRD.