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.
Integration of Benefits If you are disabled, the monthly payments under this plan will be reduced by the amount of any Periodic Payments you are entitled to apply for and receive with respect to the disability under any Workplace Safety & Insurance Act, the Canada Pension Plan or the Quebec Pension Plan. The amounts deducted will not include any additional benefits payable for children or subsequent cost of living increases.
Maintenance of Benefits With respect to negotiable wages, hours and working conditions not covered by this Agreement, the State agrees to make no changes without appropriate prior consultation and negotiations with the Association unless such change is made to comply with law, and existing regulations, Personnel Rules, written Policies and Procedures, General Orders, General Operating Procedure, or Standard Operating Procedure.
