Coordination of Benefits with Other Plans

136 views March 19, 2018 August 30, 2019 ghclienthelp 2

Industry-standard Coordination of Benefits guidelines are used whenever two benefit plans are in effect for one family. These guidelines prevent one plan from bearing the entire cost of expenses related to claims, and are outlined in your Benefits Handbook as follows:

Member
The plan under which the member is covered full-time pays first.

  • If the member is covered as a dependent under a spouse’s plan, the spouse’s plan pays second.
  • If the member has benefits with a secondary job, the plan under which the member works the most hours pays first.

Spouse
If the spouse is covered under their own plan, the spouse’s plan pays first, and the member’s plan pays second.

Dependent Children
If children are covered under both plans, the claim must first be sent to the plan of the parent whose birthday (Month/Day) is earlier in the year.

  • If both parents have the same birthday (Month/Day), the parent whose first name begins with the earlier letter of the alphabet pays first.
  • If the parents are separated or divorced, plans pay in the following order:
    1. Plan of parent with custody of child,
    2. Plan of spouse of parent with custody of child,
    3. Plan of parent who does not have custody of child, and
    4. Plan of spouse of parent without custody.

Example!

If the member’s Date of Birth is February 12 and the spouse’s Date of Birth is June 2; the member’s plan pays first.

 

The maximum amount that an member can receive from all plans is 100% of eligible expenses. When submitting a claim to the second payer, the member must attach a copy of the first payer’s Explanation of Benefits.

Coordination of Emergency Travel Assistance Plans: In the event the member and spouse both work for the same employer and they both have opted for family coverage, any Emergency Travel claim(s) will be eligible under one insured only.

 

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