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Coordination of Benefits

Most health care programs contain a coordination of benefits provision.  This provision is used when you, your spouse or your covered dependents are eligible for payment under more than one health program.  The object of coordination of benefits is to assure you that your covered expenses will be paid, while preventing duplicate benefit payments.  When your other coverage does not mention "coordination of benefits," then that coverage pays first.  Benefits paid or payable by the other coverage will be taken into account in determining if additional benefit payments can be made under your program.  When the person who received care is covered as an employee under one contract, and as a dependent under another, then the employee coverage pays first.  When a dependent child is covered under two contracts, the contract covering the parent whose birthday falls earlier in the calendar year pays first.  This is known as the Birthday Rule.  But, if both parents have the same birthday, the program which covered the parent longer will be the primary program.  If the dependent child's parents are separated or divorced, the following applies:

• if the parent with custody of the child has not remarried, the coverage of the parent with custody pays first;
• when a divorced parent with custody has remarried, the coverage of the parent with custody pays first but the stepparent's coverage pays before the coverage of the parent who does not have custody;
• regardless of which parent has custody, whenever a court decree specifies the parent who is financially responsible for the child's health care expenses, the coverage of that parent pays first.

When none of the above circumstances applies, the coverage you have had for the longest time pays first;  provided that:

• the benefits of the program covering the person as an employee other than a laid-off or retired employee or as the dependent of such person shall be determined before the benefits of a program covering the person as a laid-off or retired employee or as a dependent of such person;  and
• if the other program does not have a provision regarding laid-off or retired employees, and, as a result, the benefits of each program are determined after the other, then the provisions listed above shall not apply.

If  you receive more than you should have when your benefits are coordinated, you will be expected to repay any overpayment.  Coordination of benefits prevents duplication and works to the advantage of all members of the group.

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