Coordination of Benefits
If a participant is covered by another employer’s benefit plan or another group type health benefit plan, there may be some duplication of benefit coverage between this Plan and the other plan. This section describes how Coordination of Benefits (COB) works under the Plan.
To determine how the plans coordinate benefits, one plan is considered “primary” and the other is considered “secondary”. The primary plan pays benefits first, up to that plan’s limits. The secondary plan will not pay benefits until the primary plan pays or denies a claim. In no instance will the primary and secondary plans pay, in total, more than the actual cost of the healthcare services.
If the other plan does not include a coordination of benefits or non-duplication provision, that plan will be primary.
The following are the provisions for determining which plan will be “primary”:
Primary State & School Employees’ Health Insurance Plan
Secondary Other Health Plan
Other Health Plan
State & School Employees’ Health Insurance Plan Follow birthday rule*
Follow birthday rule*
Follow court decree
Follow court decree
Active Employee Note: If employee is covered as an “employee” under two plans, the plan covering the employee for the longest period of time is considered the primary plan.
Dependent spouse with other coverage as “active employee”
Active Employee & Spouse with children: both parents’ health pla
cover children Active Employee, divorced or separated, both parents’ health plans cover children with court order
*Under the birthday rule, the plan of the parent whose birthday falls earliest in the calendar year is the child’s primary plan. If both parents have the same birthday, the parent who has been covered longer has the primary plan. If the other plan does not have the birthday rule, then the rule in the other plan will determine which is primary.
If parents are divorced or separated and both parents’ plans cover a dependent child, benefits for the child are determined in this order:
First, the plan of the parent with custody;
Then, the plan of the stepparent (spouse of the parent with custody of the child); and
Finally, the plan of the parent not having custody of the child.