You may be covered by two or more group health benefit plans that may provide similar benefits. Should you have services covered by more than one plan, your City health plan will coordinate benefit payments with the other plan. One plan will pay its full benefit as a primary insurer, and the other plan will pay secondary benefits. This prevents duplicate payments and overpayments. In no event shall payments exceed 100% of a charge.
B. Rules of Coordination
The City program follows certain rules that have been established to determine which plan is primary; these rules apply whether or not you make a claim under both plans.
The rules for determining primary and secondary benefits are as follows:
- The plan covering you as an employee is primary before a plan covering you as a dependent.
- When two plans cover the same child as a dependent, the child's coverage will be as follows:
- The plan of the parent whose birthday falls earlier in the year provides primary coverage.
- If both parents have the same birthday, the plan that has been in effect the longest is primary.
- If the other plan has a gender rule (stating that the plan covering you as a dependent of a male employee is primary before a plan covering you as a dependent of a female employee), the rule of the other plan will determine which plan will cover the child. (See Section C for special rules concerning dependents of separated or divorced parents.)
- If no other criteria apply, the plan covering you the longest is primary. However, the plan covering you as a laid-off or retired employee, or as a dependent of such a person, is secondary, and the plan covering you as an active employee, or as a dependent of such a person, is primary, as long as the other plan has a COB provision similar to this one.
C. Rules for Dependents of Separated or Divorced Parents
If two or more plans cover a dependent child of divorced or separated parents, benefits are to be determined in the following order:
- The plan of the parent who has custody of the child is primary.
- If the parent with custody of a dependent child remarries, that parent's plan is primary. The step-parent's plan is secondary and the plan covering the parent without custody is tertiary (third).
- If the specific decree of the court states one parent is responsible for the health care of the child, the benefits of that parent's plan are determined first. You must provide the appropriate plan with a copy of the portion of the court order showing responsibility for health care expenses of the child.
D. Effect of Primary and Secondary Benefits
- Benefits under a plan that is primary are calculated as though other coverage did not exist.
- Benefits under a plan that is secondary will be reduced so that the combined payment or benefit from all plans are not more than the actual charges for the covered service. The plan that is secondary will never pay more than its full benefits.
The Health Benefits Program will not provide benefits for any services for which benefits are available under a no-fault automobile policy.