Coordination of Benefits Sample Clauses

Coordination of Benefits i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits under any other group or pre-paid plan or insurance plan designed to fully integrate with other plans. If this plan is the “primary” plan, Delta Dental will not reduce Benefits. If this plan is the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental determine which Plan is the “primary” plan? 1) The plan covering the Enrollee as an employee is primary over a plan covering the Enrollee as a dependent. 2) The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; but b) if both parents have the same birthday, the benefits of the plan covering one parent longer are determined before those of the plan covering the other parent for a shorter period of time. c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parents, the plan covering the Enrollee as a dependent of the parent with legal custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to t...

Coordination of Benefits. The Public Employee Benefits Board (PEBB) may adopt any of the effect-on-benefit alternatives described in the National Association of Insurance Commissioners (NAIC) 1985 model acts and regulations, or any subsequent alternatives promulgated by the NAIC.

Coordination of Benefits. The coordination of benefits (COB) provision applies when a Member has health care coverage under more than one plan. Plan is defined below. The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits according to its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. In no event will a secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. If the Member is covered by more than one health benefit plan, and the Member does not know which is the primary plan, the Member or the Member’s provider should contact any one of the health plans to verify which plan is primary. The health plan the Member contacts is responsible for working with the other plan to determine which is primary and will let the Member know within 30 calendar days. All health plans have timely claim filing requirements. If the Member or the Member’s provider fails to submit the Member’s claim to a secondary health plan within that plan’s claim filing time limit, the plan can deny the claim. If the Member experiences delays in the processing of the claim by the primary health plan, the Member or the Member’s provider will need to submit the claim to the secondary health plan within its claim filing time limit to prevent a denial of the claim. If the Member is covered by more than one health benefit plan, the Member or the Member’s provider should file all the Member’s claims with each plan at the same time. If Medicare is the Member’s primary plan, Medicare may submit the Member’s claims to the Member’s secondary carrier.

Coordination of Benefits. In the event a member is covered under another plan or policy which provides coverage, benefits or services (plan) that are covered benefits under this dental plan, then the benefits of this plan shall be coordinated with the other plan according to regulations on “Coordination of Benefits”. Covered California’s standard benefit design requires that stand alone dental plans offering the pediatric dental essential health benefit, such as this CDN plan, whether as a separate benefit or combined with a family dental benefit, cover benefits as a secondary dental benefit plan payer. This means that the primary dental benefit payer is a health plan purchased through Covered California which includes pediatric dental essential health benefits. Your primary dental benefit plan will pay the maximum amount required by its plan contract with you when your primary dental benefit plan is coordinating its benefits with CDN. This means that CDN will pay the lesser of either the amount that it would have paid in the absence of any other dental benefit coverage when a primary dental benefits plan is coordinating benefits with your CDN plan, or your total out-of- pocket cost payable under the primary dental benefit plan for benefits covered under your CDN plan. These regulations determine which plan is primary and which is secondary under various circumstances. Generally, they result in a group plan being primary over an individual plan and that a plan covering the member as a subscriber is primary over a plan covering the member as a dependent. Typically, Coordination of Benefits will result in the following: If the other coverage is a group indemnity plan: • If the group indemnity coverage is primary, the provider will usually bill the carrier for their Usual and Customary Fees, and the member will be charged the copayment under the secondary plan less the amount received from the primary coverage. • If the group indemnity coverage is secondary, the provider will bill the carrier for the amount of copayments under the primary plan, and the member will be responsible for the copayments under the primary plan less the amount paid by the secondary carrier. If the other coverage is a prepaid plan: • If the provider participates in both plans, the member should be charged the lower copayment(s) of the two plans. • If the provider does not participate in both plans, the plan that the provider participates in will be primary, and the other plan will typically deny coverage becau...

Coordination of Benefits. When an employee is eligible at the same time for benefits under Chapter 616 or 617 of the Nevada Revised Statutes and for sick leave or injury leave benefit, the amount of sick leave or injury leave benefit paid to said employee shall not exceed the differences between their normal salary and the amount of any benefit received, exclusive of payment of medical or hospital expenses under Chapter 616 or 617 of the Nevada Revised Statutes for that pay period. Any usage of such sick leave shall be deducted from the employee’s sick leave balance.

Coordination of Benefits. Employees who are absent due to illness or injury covered by workers’ compensation benefits may use accrued sick leave to make up the difference between the employee’s regular salary and the amount received in workers’ compensation benefits, taking into account the tax-free nature of workers’ compensation benefits.

Coordination of Benefits. ILS Community Network or Managed Care Plan will coordinate benefits in accordance with Mandates and in accordance with its health care benefit contracts. Provider shall cooperate with Managed Care Plan or its delegee so as to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and coordination of benefit guidelines. Provider agrees to bill other payor(s) with the primary liability (including the Medicare program, if the recipient is eligible for payment for health care or related services from another insurer or person and comply with all other State and Federal requirements in this regard) prior to submitting bills for the same services to Managed Care Plan or its delegee. Provider also agrees to provide Managed Care Plan or its delegee with relevant information it has collected from Enrollees regarding coordination of benefits. If Managed Care Plan is not Enrollee's primary payor, Provider's compensation by Managed Care Plan or its delegee shall be no more than the difference between the amount paid by the primary payor(s) and the applicable rate under this Agreement, less any applicable Co-payments or Co-insurance. 4.3.1 Provider payment will not be delayed due to ILS Community Network or Managed Care Plan recovery efforts from Third Parties. In cases where a Enrollee has coverage, other than with ILS Community Network or Managed Care Plan, which requires or permits coordination of benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s). ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this Agreement, or (ii) the amount due under this Agreement less the amount payable or to be paid by the other payor(s), or (iii) the difference between allowed billed charges and the amount paid by the other payor(s). In the event Medicare is the primary payor, ILS Community Network or Managed Care Plan shall pay Provider the amount of deductible, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the Social Security Act, as amended, subject to the benefit limits and applicable rates of the applicable health care benefits contract. In no event will ILS Community Network or Managed Care Plan pay a monetary amount which when combined with payments from the othe...

Coordination of Benefits. If a Contractor’s QHP provides coverage for the Pediatric Dental Essential Health Benefit, Contractor shall include a Coordination of Benefits (COB) provision in its Evidence of Coverage or Policy Form that (i) is consistent with Health and Safety Code § 1374.19 or Insurance Code § 10120.2, and (ii) provides that the QHP is the primary dental benefit plan or policy under that COB provision. This provision shall apply to Contractor’s QHPs offered both inside and outside of Covered California for the Individual Market, except where 28 CCR § 1300.67.13 or 10 CCR § 2232.56 provides for a different order of determination for COB in the small group market.

Coordination of Benefits. Contractor’s Qualified Dental Plans shall include a Coordination of Benefits (COB) provision in its Evidence of Coverage or Policy Form that (1) is consistent with Health and Safety Code § 1374.19 and Insurance Code § 10120.2 and (2) provides that the Qualified Dental Plan is the secondary dental benefit plan or policy under that COB provision to any Qualified Health Plan that provides the Pediatric Dental Essential Health Benefit. This provision shall apply to Contractor’s QDPs offered both inside and outside of the Covered California for the Individual Market and Covered California for Small Business, except where 28 CCR § 1300.67.13 or 10 CCR § 2232.56 provides for a different order of determination for COB in the small group market.

Coordination of Benefits. Note: If a Member participating in a Health Savings Account has other health care coverage, the tax deductibility of Health Savings Account contributions may be affected. Please contact the Health Savings Account trustee or administrator regarding questions about requirements for Health Savings Accounts.