Coordination of Benefits

The OLDC-OCA Insurance Fund has been designed to help you meet the cost of medical insurance. It is not intended that you receive greater benefits than your actual health care expenses. If you and/or your dependents are covered under another plan, you must report all other coverage when you file a claim. The amount in benefits payable under the Fund will be coordinated with any coverage covered individuals have under any:

  • Group, blanket, or franchise insurance coverage
  • Group coverage or group-type coverage through HMOs and other prepayment, group practice, and individual practice plans
  • Coverage under employment benefit welfare plans as defined by ERISA
  • Coverage under any plan largely tax-supported or otherwise provided for by or through action of any government and any coverage required or provided by any statue (except Medicare)
  • Plan that is paid for entirely by a covered individual only if the plan contains a provision for coordinating benefits
  • Part A and Part B of Medicare, regardless of whether or not the covered individual is enrolled

The Insurance Plan will always cover either its regular benefits in full or a reduced amount that, when added to the benefits payable by the other plan(s), will equal the total allowable expenses. (Allowable expenses are any necessary, usual, customary, and reasonable charge at least part of which is covered under one of the plans covering the member or dependent.) If a plan provides benefits in the form of services or supplies instead of cash, the reasonable cash value of the service rendered and supplies furnished (if otherwise an allowable expense) will be considered both an allowable expense and a benefit paid. However, no more than the maximum benefits payable under this Fund will be paid. 

Please note that you must file a claim for any benefits you are entitled to from any other source. Whether or not you file a claim with any other source, your payments from this Fund will be calculated as though you have received any benefits you are entitled to from other sources. In additional, you must comply with all rules of any other plan. If you do not and benefits are reduced from the other plan for failure to follow the appropriate procedures, benefits paid under this Fund will be limited to the amount that would have been paid had you followed the appropriate procedures. 

Order of Payment

If you and/ or your dependent(s) are covered under more than one plan, the primary plan pays first, regardless of the amount payable under any other plan. The other (secondary) plan will adjust its benefit payment so that the total benefits payable do not exceed 100% of the allowable expense incurred. 

In general, a plan that covers an individual as an employee is primary. If an individual is an employee under more than one plan or no other rule determines the order of payment, the plan that has covered the individual longer is primary. 

If a dependent child is covered under more than one plan and the parents are not divorced or legally separated, the following rules determine which plan’s benefits are primary:

  • The plan that covers the parent whose date of birth occurs earlier in the calendar year, excluding the birth year, is primary. This is known as the birthday rule. 
  • If the birthday of both parents occurs on the same date, the plan that covered the parent fro the longer period of time is primary.
  • If a plan does not use the birthday rule to determine which pays first, the rules of that plan determine the order of benefit payments, provided the rules are based on the parents’ gender, in which care, the rules of the other plan will not be followed and the Fund will follow the birthday rule. 
If a dependent child is covered under more than one plan and the parents are divorced or legally separated, the following rules determine which plan’s benefits are primary:
  • Where there is a court decree that establishes financial responsibility for medical expenses, the plan covering the dependent child of the parent who has financial responsibility will pay first. 
  • Where there is no court decree or a court order does not specify which plan is primary, the plan of the parent with custody is primary. If the parent with custody has remarried, then:
    • The stepparent with custody of the child pays second; and
    • The  parent not having custody of the child pays third. 
If the Fund makes payments it is not required to pay, it may recover and collect those payments from you, your dependent, or any organization or insurance company that should have made the payment. The Fund’s right to reimbursement under the Subrogation and Reimbursement provision of the SPD chall also apply in those instances where the Fund has made payments it is not required to pay. 
 

Coordination of Benefits with Managed Care Plans

If you or your dependents are covered by a managed care plan, such as a Health Maintenance Organization (HMO) plan, the Fund will assume that you and your dependents have complied with that plan’s rules necessary for your expenses to be covered by the managed care plan. This Fund is not responsible for medical expenses that could have been paid or would otherwise be paid under the managed care plan had you followed that plan’s rules. If the managed care plan is considered the primary plan and is not used, this Fund payment will be limited to the amount that would have been payable had the covered individual followed the Fund requirements. 

For information on Coordination of Benefits with Medicare, please review the Insurance SPD

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