Child Covered Under More Than One Plan Sample Clauses

Child Covered Under More Than One Plan. The order of benefits when a child is covered by more than one plan is: a. The primary plan is the plan of the parent whose birthday is earlier in the year if: • The parents are married; • The parents are not separated (whether or not they ever have been married); or • A court decree awards joint custody without specifying that one party has the responsibility to provide health care coverage. If both parents have the same birthday, the plan that covered either of the parents for a longer time is primary. b. If the specific terms of a court decree state that one of the parents is responsible for the child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms; then that plan is primary. This rule applies to claim determination periods or plan years commencing after the plan is given notice of the court decree. c. If the parents are not married, or are separated (whether or not they ever have been married) or are divorced, the order of benefits is: • The plan of the custodial parent; • The plan of the spouse of the custodial parent; • The plan of the non-custodial parent; and then • The plan of the spouse of the non-custodial parent. d. For a child covered under more than one plan by persons who are not the parents of such child, the order of benefits shall be determined under paragraph 4.a. of this section as if those persons were parents of such child. e. For a dependent child who has coverage under either or both parents’ plans and also has coverage as a dependent under a spouse’s plan, the rule in paragraph 7 of this section applies. In the event the dependent child’s coverage under the spouse’s plan began on the same date as the dependent child’s coverage under either or both parents’ plans, the order of benefits shall be determined by applying the birthday rule in paragraph 4.a of this section to the dependent child’s parent(s) and the dependent child’s spouse.
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Child Covered Under More Than One Plan. Unless there is a court decree stating otherwise, when a child is covered by more than one Plan, the order of benefits is determined as follows: (i) For a child whose parents are married or are living together, whether or not they have ever been married: • The Plan of the parent whose birthday falls earlier in the calendar year is the primary Plan. This is known as the Birthday Rule; or • If both parents have the same birthday, the Plan that has covered the parent the longest is the Primary Plan; or • If one of the Plans does not follow the Birthday Rule, then the Plan of the child’s father is the Primary Plan. This is known as the Gender Rule. (ii) For a child whose parents are divorced, separated or not living together, whether or not they have ever been married: • If a court decree states that one of the parents is responsible for the child’s health care expenses or coverage and the Plan of that parent has actual knowledge of this decree, that Plan is primary. This rule applies to plan years commencing after the Plan is given notice of the court decree; • If a court decree states that both parents are responsible for the child’s health care expenses or coverage, the provisions of subparagraph (i) determine the order of benefits; • If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or coverage of the child, the provisions of subparagraph (i) determine the order of benefits; or • If there is no court decree allocating responsibility for the child’s health care expenses or coverage, the order of benefits for the child is as follows: • The Plan covering the Custodial Parent; • The Plan covering the spouse of the Custodial Parent; • The Plan covering the non-custodial parent; and then • The Plan covering the spouse of the non-custodial parent. (iii) For a child covered under more than one Plan of individuals who are not the parents of the child, the provisions of Subparagraph (i) or (ii) above shall determine the order of benefits as if those individuals were the parents of the child.
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Child Covered Under More Than One Plan. The order of benefits when a child is covered by more than one plan is:
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Related to Child Covered Under More Than One Plan

  • When You Have More Than One Plan with BCBSRI If you are covered under more than one plan with us, you are entitled to covered benefits under both plans. If one plan has a benefit that the other(s) does not, you are entitled to coverage under the plan that has the benefit. The total payments you receive will never be more than the total allowable expense for the services you receive.

  • When You Are Covered by More Than One Insurer A healthcare coverage plan is considered the primary plan and its benefits will be paid first if: • the plan does not use similar COB rules to determine coverage; or • the plan does not have a COB provision; or • The plan has similar the COB rules and is determined to be primary under the order of benefit determination rules described below. Benefits under another plan include all benefits that would be paid if claims had been initially submitted under that plan. The following factors are used to determine which plan is primary and which plan is • if you are the main subscriber or a dependent; • if you are married, which spouse was born earlier in the year; • the length of time each spouse has been covered under the plan; • if a parental custody or divorce decree applies; or • if Medicare is your other coverage then Medicare guidelines will apply. These factors make up the order of benefit determination rules, described in greater detail below:

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