Service Employees 32BJ North Health Fund

Tri-State Preferred North Summary Plan Description (SPD) >> Coordination of Benefits

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You or your dependents may have health care coverage under two plans. For example, your spouse may have employer-provided health insurance or be enrolled in Medicare. When this happens, the two plans will coordinate their benefit payments so that the combined payments do not exceed the allowable charges (or actual cost, if less). This process, known as Coordination of Benefits (COB), establishes which plan pays first and which one pays second. The plan that pays first is the primary plan; the plan that pays second is the secondary plan. The primary plan will reimburse you first and the secondary plan will reimburse you for the remaining expenses to the maximum of the allowable charges for the covered services.

Coordination of Benefits will ensure that you receive the maximum benefit allowed, while possibly reducing the cost of services to the Plan. You will not lose benefits and may gain benefits if your spouse’s plan has better coverage in any area.

Except for the situations like Medicare and TRI-CARE described below, the rules for determining which plan is primary are as follows:

• If the other plan does not have a coordination of benefits provision with regard to the particular expense, that plan is always primary.

• The plan that covers the patient as an active employee is primary and the plan that covers the patient as a dependent is secondary.

• If the patient is covered both as an active employee (or as a dependent of an active employee) and as either a laid-off employee or a retired employee, then the active employee’s plan will be primary. However, if the other plan does not have this rule and the two plans do not agree as to which coverage is primary, then this rule will not apply.

• If the patient is a dependent child of parents who are not separated or divorced, then the plan covering the parent whose birthday falls earlier in the calendar year is primary and pays first. If the other plan does not use this “birthday rule,” then that plan is primary unless the primary plan is already determined under the above rules.

• If the patient is a dependent child of parents who are legally separated or divorced, the plan of the parent with custody will be primary; the other parent’s plan will be secondary. In the event the parent with custody has remarried, the plan of the parent (or stepparent) with custody will be primary and the plan of the parent without custody will be secondary. If there is a court decree giving one parent financial responsibility for the medical expenses, then that parent’s plan becomes primary without regard to the other rules in this paragraph.

• If none of the above rules establishes which plan is the primary plan, the plan that has covered the patient the longest, continuously, in the period of coverage in which the expense is incurred is the primary plan.

If both you and your spouse are participants under this Plan, your benefits are coordinated in the same manner as anyone else (that is, as if you and your spouse were covered under different plans). You will not receive reimbursement for more than the allowable charges for the covered services, and you will not be reimbursed for required co-payments.

Medicare.

• If you (or a dependent) become eligible for Medicare due to age or disability (according to the standards applied by Social Security) and you are in covered employment, you or your dependent(s) can keep or cancel (spouse can cancel when he or she reaches age 65) your coverage under this Plan. If you (or your dependent) decide to be covered by both this Plan and Medicare, this Plan will be primary and Medicare will be secondary as long as you remain in covered employment.

• If you are not in covered employment (for example, you have extended health coverage while receiving disability benefits) and you (or a dependent) are eligible for Medicare due to age or disability (according to the standards applied by Social Security), Medicare is primary and this Plan is secondary for each covered family member who is eligible for Medicare. Those covered family members who are not eligible for Medicare continue to receive primary coverage from this Plan.

End-stage Renal Disease.

For covered patients with end-stage renal disease, Medicare is the secondary payer of benefits during the first 30 months of treatment. After this 30-month period is over, Medicare permanently becomes the primary payer. Note that this Plan will pay as the secondary plan after the 30-month period even if you (or your dependent) fail to enroll in Medicare Part B.

TRI-CARE.

If you or an eligible dependent are covered by this Plan and TRI-CARE, this Plan pays first and TRI-CARE pays second.

No-fault Benefits.

If a person covered by this Plan has a claim, which involves a motor vehicle accident covered by the “no-fault” insurance law of any state, health care expenses must be reimbursed first by the no-fault insurance carrier. Only when the claimant has exhausted his or her health care benefits under the no-fault coverage will he or she be entitled to receive health care benefits under this Plan. If there are expenses for services that are covered under this Plan and which are not completely reimbursed by the no-fault carrier, such expenses may be reimbursed under this Plan, subject to the Plan’s applicable maximums and other provisions.

Other Coverage Provided By State or Federal Law.

If you are covered by both this Plan and any other insurance provided by any other state or Federal law, the insurance provided by any other state or Federal law pays first and this Plan pays second.

Workers' Compensation.

This Plan does not provide benefits for expenses covered by Workers’ Compensation or occupational disease laws. If an employer disputes the application of Workers’ Compensation law for the illness or injury for which expenses are incurred, the Plan will pay benefits, subject to its right to recover those payments if and when it is determined that they are covered under a Workers’ Compensation or occupational disease law (for information about subrogation and reimbursement of benefits, see the "Subrogation and Reimbursement" section).