Common use of Effect on Benefits Clause in Contracts

Effect on Benefits. a. This provision shall apply in determining the benefits for a Member covered under the Agreement for a particular claim determination period if, for the allowable expenses incurred by the Member during such period, the sum of: i. The reasonable cash value of the benefits that would be provided under the Agreement in the absence of this provision, and ii. The benefits that would be payable under all other plans in the absence therein or provisions of similar purpose to this provision would exceed such allowable expenses. b. As to any claim determination period with respect to which this provision is applicable, the reasonable cash value of the benefits provided under the Agreement in the absence of this provision for the allowable expenses incurred as to such person during such claim determination period shall be reduced to the extent necessary so that the sum of the reasonable cash value of benefits and all benefits payable for such allowable expenses under all other plans, except as provided in subparagraph c. of this section, shall not exceed the total of such allowable expenses. Benefits payable under another plan include benefits that would have been payable had a claim been duly made therefor. In determining liability under this paragraph, GHC is not required, and will not take into consideration, Deductibles, Copayments or other Cost Share provisions. c. If another plan which is involved in subparagraph b. of this section and which contains a provision coordinating its benefits with those of the Agreement would, according to its rules, determine its benefits after the benefits of this plan have been determined; and the rules set forth in subparagraph d. of this section would require the Agreement to determine its benefits before such other plan, then the benefits of such other plan will be ignored for the purposes of determining the benefits under the Agreement. d. For the purposes of subparagraph c. of this section, the rules establishing the order of benefit determination are: i. The benefits of a plan which covers the person on whose expenses a claim is based as a Subscriber shall be determined before the benefits of a plan which covers such person as a Dependent. ii. If a Dependent is covered under both parents' medical plans, the benefits of the plan of the parent whose birthday, excluding year, falls earlier in the calendar year are determined before those of the plan of a parent whose birthday, excluding year, falls later in the calendar year. a) When the parents are separated or divorced and the parent with custody of the child has not remarried, the benefits of a plan which covers the child as a Dependent of the parent with custody of the child will be determined before the benefits of a plan which covers the child as a Dependent of the parent without custody; and b) When the parents are divorced and the parent with custody of the child has remarried, the benefits of a plan which covers the child as a Dependent of the parent with custody shall be determined before the benefits of a plan which covers that child as a Dependent of the stepparent, and the benefits of a plan which covers that child as a Dependent of the stepparent will be determined before the benefits of a plan which covers that child as a Dependent of the parent without custody. Notwithstanding items a) and b) above, if there is a court decree which would otherwise establish financial responsibility for the health care expenses of the child, the benefits of a plan which covers the child as a Dependent of the parent with such financial responsibility shall be determined before the benefits of any other plan which covers the child as a Dependent. iii. When rules i. and ii. do not establish an order of benefit determination, the benefits of a plan which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the benefits of a plan which has covered such person the shorter period of time, provided that: a) The benefits of a plan covering the person as a laid off or retired employee, or Dependent of such person shall be determined after the benefits of any other plan covering such person as an employee, other than a laid off or retired employee, or Dependent of such person; and b) If either plan does not have a provision regarding laid off or retired employees, which results in each plan determining its benefits after the other, then the provisions of a) of this subsection shall not apply. iv. If none of the above rules determines the order of benefits, the benefits of the plan which covered an employee, Member or Subscriber for the longer period of time shall be determined before those of the plan which covered that person for the shorter time period. e. When this provision operates to reduce the total amount of benefits otherwise to be provided to a person covered under the Agreement during any claim determination period, the reasonable cash value of each benefit that would be provided in the absence of this provision shall be reduced proportionately and such reduced amount shall be charged against any applicable benefit limit of the Agreement.

Effect on Benefits. a. This provision shall apply in determining When the Carrier’s Plan is secondary, the benefits for a Member covered under this Plan will be reduced so that the Agreement for a particular claim determination period ifCarrier will pay no more than the difference, for the allowable expenses incurred by the Member during such periodif any, the sum of: i. The reasonable cash value of the benefits that would be provided under the Agreement in the absence of this provision, and ii. The benefits that would be payable under all other plans in the absence therein or provisions of similar purpose to this provision would exceed such allowable expenses. b. As to any claim determination period with respect to which this provision is applicable, the reasonable cash value of between the benefits provided under the Agreement in other Plan for services covered under this Plan and the absence of this provision for the allowable expenses incurred as to such person during such claim determination period shall be reduced total Covered Services provided to the extent necessary so that the sum of the reasonable cash value of benefits and all benefits payable for such allowable expenses under all other plans, except as provided in subparagraph c. of this section, shall not exceed the total of such allowable expensesEmployee. Benefits payable under another plan Plan include benefits that would have been payable had a the claim been duly made therefortherefore. In determining liability no event will the Carrier payment exceed the amount that would have been payable under this paragraphPlan if the Carrier were primary. When the benefits are reduced under the primary Plan because an Employee does not comply with the Plan provision, GHC is or does not requiredmaximize benefits available under the primary Plan, and the amount of such reduction will not take into considerationbe considered an allowable benefit. Examples of such provisions are Penalties and increased Coinsurance related to Precertification of admissions and services, DeductiblesPreferred Provider arrangements and other cost-sharing features. Certain facts are needed to apply COB. The Carrier has the right to decide which facts are needed. The Carrier may, Copayments without consent of or notice to any person, release to or obtain from any other Cost Share provisions. c. If another plan organization or person any information, with respect to any person, which is involved in subparagraph b. of the Carrier deems necessary for such purposes. Any person claiming benefits under this section and which contains a provision coordinating its benefits with those of Plan shall furnish to the Agreement wouldCarrier such information as may be necessary to implement this provision. The Carrier, according to its ruleshowever, determine its benefits after the benefits of this plan have been determined; and the rules set forth in subparagraph d. of this section would require the Agreement shall not be required to determine its the existence of any other Plan or the amount of benefits before payable under any such other plan, then the benefits of such other plan will be ignored for the purposes of determining the benefits under the Agreement. d. For the purposes of subparagraph c. of this section, the rules establishing the order of benefit determination are: i. The benefits of a plan which covers the person on whose expenses a claim is based as a Subscriber shall be determined before the benefits of a plan which covers such person as a Dependent. ii. If a Dependent is covered under both parents' medical plans, the benefits of the plan of the parent whose birthday, excluding year, falls earlier in the calendar year are determined before those of the plan of a parent whose birthday, excluding year, falls later in the calendar year. a) When the parents are separated or divorced and the parent with custody of the child has not remarried, the benefits of a plan which covers the child as a Dependent of the parent with custody of the child will be determined before the benefits of a plan which covers the child as a Dependent of the parent without custody; and b) When the parents are divorced and the parent with custody of the child has remarried, the benefits of a plan which covers the child as a Dependent of the parent with custody shall be determined before the benefits of a plan which covers that child as a Dependent of the stepparentPlan, and the payment of benefits of a plan which covers that child as a Dependent of the stepparent will under this Plan shall be determined before affected by the benefits of a plan which covers that child as a Dependent of the parent without custody. Notwithstanding items a) and b) above, if there is a court decree which would otherwise establish financial responsibility for the health care expenses of the child, the benefits of a plan which covers the child as a Dependent of the parent with such financial responsibility shall be determined before the benefits of any other plan which covers the child as a Dependent. iii. When rules i. and ii. do not establish an order of benefit determination, the benefits of a plan which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the benefits of a plan which has covered such person the shorter period of time, provided that: a) The benefits of a plan covering the person as a laid off or retired employee, or Dependent of such person shall be determined after the benefits of any other plan covering such person as an employee, other than a laid off or retired employee, or Dependent of such person; and b) If either plan does not have a provision regarding laid off or retired employees, which results in each plan determining its benefits after the other, then the provisions of a) of this subsection shall not apply. iv. If none of the above rules determines the order of benefits, the benefits of the plan which covered an employee, Member or Subscriber for the longer period of time shall be determined before those of the plan which covered that person for the shorter time period. e. When this provision operates to reduce the total amount of benefits otherwise to be provided to a person covered under the Agreement during any claim determination period, the reasonable cash value of each benefit that would be provided in payable under any and all other Plans only to the absence of this provision shall be reduced proportionately and extent that the Carrier is furnished with information relative to such reduced amount shall be charged against any applicable benefit limit of the Agreementother Plans.

Effect on Benefits. a. This provision Subsection shall apply in determining the benefits for a Member covered payable under the this Agreement for a particular claim determination period if, for the allowable expenses incurred by the Member during such periodCovered Services received, the sum of: i. The reasonable cash value of the benefits that payable under this Agreement and the benefits payable under Other Agreements would exceed the total Allowable Expense. b. Except as provided in Paragraph 2c. of this Subsection, when this Agreement is a Secondary Agreement, benefits will be provided under calculated based on what the Agreement Plan would have paid on the claim in the absence of other health care coverage and apply that calculated amount to any Allowable Expense under this provision, and iiAgreement that is unpaid under the Primary Agreement. The Plan may reduce its payment by the amount so that, when combined with the amount paid under the Primary Agreement, the total benefits that would be payable paid or provided under all other plans in agreements for the absence therein or provisions of similar purpose to this provision would claim do not exceed such allowable expenses. b. As to any claim determination period with respect to which this provision is applicablethe total Allowable Expense for that claim. In addition, the reasonable cash value of Plan shall credit to the benefits provided under the Agreement applicable Deductible any amounts it would have credited to that Deductible in the absence of this provision for the allowable expenses incurred as to such person during such claim determination period shall be reduced to the extent necessary so that the sum of the reasonable cash value of benefits and all benefits payable for such allowable expenses under all other plans, except as provided in subparagraph c. of this section, shall not exceed the total of such allowable expenseshealth care coverage. Benefits payable under another plan Other Agreements include the benefits that would have been payable had a claim been duly made therefor. In determining liability under this paragraph, GHC is not required, and will not take into consideration, Deductibles, Copayments or other Cost Share provisionsmade. c. If another plan which is involved in subparagraph b. of this section and which If, i) an Other Agreement contains a provision coordinating its benefits with those of the this Agreement would, according to and its rules, determine its benefits after rules require the benefits of this plan have been determinedAgreement to be determined first; and and ii) the rules set forth in subparagraph d. Paragraph 2.d. of this section would Subsection require the benefits of this Agreement to determine its benefits before such other plan, be determined first; then the benefits of such other plan the Other Agreement will be ignored for the purposes of in determining the benefits under the this Agreement. d. For the purposes of subparagraph c. of this section, the rules establishing the This Agreement determines its order of benefit determination arebenefits using the first of the following rules which applies: i. i) The benefits of a plan an agreement which covers the person on whose expenses as other than a claim is based as a Subscriber Dependent shall be determined before first; ii) When this Agreement and an Other Agreement cover the person as a Dependent of different parents: (a) the benefits of a plan the agreement which covers such the person as a Dependent.Dependent of the parent whose birthday (excluding year of birth) falls earliest in the year shall be determined first; but, ii. If a Dependent is covered under (b) if both parents' medical plansparents have the same birthday, the benefits of the plan of agreement which covered the parent whose birthday, excluding year, falls earlier in the calendar year longer are determined before those of the plan Agreement which covered the other parent for a shorter period of time. However, if the Other Agreement does not have the rule described in item (a) above, but instead has a parent whose birthdayrule based upon the gender of the parent, excluding yearand if, falls later as a result, the agreements do not agree on the order of benefits, the rule in the calendar yearOther Agreement will determine the order of benefits. iii) If two (2) or more agreements cover a Dependent child of divorced or separated parents, benefits for the child are determined in this order: (a) When First, the parents are separated or divorced and agreement covering the parent with custody of the child has child; (b) then, the agreement of the spouse of the parent with custody of the child; and (c) finally, the agreement of the parent not remarriedhaving custody of the child. However, if there is a court decree which establishes a parent’s financial responsibility for the child’s health care expenses, the benefits of a plan the agreement which covers the child as a Dependent of that parent shall be determined first. This paragraph does not apply with respect to any Benefit Period during which any benefits are actually paid or provided before the parent with custody entity obligated to pay or to provide benefits under that parent’s agreement has actual knowledge of the child will be determined before the court decree. iv) The benefits of the agreement covering the person as an employee other than a plan which covers the child laid-off or retired employee or as a Dependent of the parent without custody; and b) When the parents are divorced and the parent with custody of the child has remarried, the benefits of a plan which covers the child as a Dependent of the parent with custody such person shall be determined before the benefits of a plan which covers that child as a Dependent of the stepparent, and the benefits of a plan which covers that child as a Dependent of the stepparent will be determined before the benefits of a plan which covers that child as a Dependent of the parent without custody. Notwithstanding items a) and b) above, if there is a court decree which would otherwise establish financial responsibility for the health care expenses of the child, the benefits of a plan which covers the child as a Dependent of the parent with such financial responsibility shall be determined before the benefits of any other plan which covers the child as a Dependent. iii. When rules i. and ii. do not establish an order of benefit determination, the benefits of a plan which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the benefits of a plan which has covered such person the shorter period of time, provided that: a) The benefits of a plan agreement covering the person as a laid laid-off or retired employee, employee or Dependent of such person shall be determined after the benefits of any other plan covering such person as an employee, other than a laid off or retired employee, or Dependent of such person; and b) . If either plan the Other Agreement does not have a this provision regarding laid laid-off or retired employeesemployees and, which results in each plan determining its benefits after as a result, the otheragreements do not agree on the order of benefits, then the provisions of a) of this subsection shall not applyrule is disregarded. iv. v) If none of the above rules determines the order of benefits, the benefits of the plan agreement which has covered an employee, Member or Subscriber the person for the longer longest period of time shall be determined before those of the plan which covered that person for the shorter time periodfirst. e. When this provision operates to reduce If an Other Agreement does not contain provisions establishing the total amount same order of benefits otherwise to be provided to a person covered under the Agreement during any claim benefit determination periodrules, the reasonable cash value of each benefit benefits under that would agreement will be provided in determined before the absence of benefits under this provision shall be reduced proportionately and such reduced amount shall be charged against any applicable benefit limit of the Agreement.

Effect on Benefits. a. This provision Subsection shall apply in determining the benefits for a Member covered payable under the this Agreement for a particular claim determination period if, for the allowable expenses incurred by the Member during such periodCovered Services received, the sum of: i. The reasonable cash value of the benefits that payable under this Agreement and the benefits payable under Other Agreements would exceed the total Allowable Expense. b. Except as provided in Paragraph 2.c. of this Subsection, when this Agreement is a Secondary Agreement, benefits will be provided under calculated based on what the Agreement Plan would have paid on the claim in the absence of other health care coverage and apply that calculated amount to any Allowable Expense under this provision, and iiAgreement that is unpaid under the Primary Agreement. The Plan may reduce its payment by the amount so that, when combined with the amount paid under the Primary Agreement, the total benefits that would be payable paid or provided under all other plans in agreements for the absence therein or provisions of similar purpose to this provision would claim do not exceed such allowable expenses. b. As to any claim determination period with respect to which this provision is applicablethe total Allowable Expense for that claim. In addition, the reasonable cash value of Plan shall credit to the benefits provided under the Agreement applicable Deductible any amounts it would have credited to that Deductible in the absence of this provision for the allowable expenses incurred as to such person during such claim determination period shall be reduced to the extent necessary so that the sum of the reasonable cash value of benefits and all benefits payable for such allowable expenses under all other plans, except as provided in subparagraph c. of this section, shall not exceed the total of such allowable expenseshealth care coverage. Benefits payable under another plan Other Agreements include the benefits that would have been payable had a claim been duly made therefor. In determining liability under this paragraph, GHC is not required, and will not take into consideration, Deductibles, Copayments or other Cost Share provisionsmade. c. If another plan which is involved in subparagraph b. of this section and which If, i) an Other Agreement contains a provision coordinating its benefits with those of the this Agreement would, according to and its rules, determine its benefits after rules require the benefits of this plan have been determinedAgreement to be determined first; and and ii) the rules set forth in subparagraph d. Paragraph 2.d. of this section would Subsection require the benefits of this Agreement to determine its benefits before such other plan, be determined first; then the benefits of such other plan the Other Agreement will be ignored for the purposes of in determining the benefits under the this Agreement. d. For the purposes of subparagraph c. of this section, the rules establishing the This Agreement determines its order of benefit determination arebenefits using the first of the following rules which applies: i. i) The benefits of a plan an agreement which covers the person on whose expenses as other than a claim is based as a Subscriber Dependent shall be determined before first; ii) When this Agreement and an Other Agreement cover the person as a Dependent of different parents: (a) the benefits of a plan the agreement which covers such the person as a Dependent.Dependent of the parent whose birthday (excluding year of birth) falls earliest in the year shall be determined first; but, ii. If a Dependent is covered under (b) if both parents' medical plansparents have the same birthday, the benefits of the plan of agreement which covered the parent whose birthday, excluding year, falls earlier in the calendar year longer are determined before those of the plan Agreement which covered the other parent for a shorter period of time. However, if the Other Agreement does not have the rule described in item (a) above, but instead has a parent whose birthdayrule based upon the gender of the parent, excluding yearand if, falls later as a result, the agreements do not agree on the order of benefits, the rule in the calendar yearOther Agreement will determine the order of benefits. iii) If two (2) or more agreements cover a Dependent child of divorced or separated parents, benefits for the child are determined in this order: (a) When First, the parents are separated or divorced and agreement covering the parent with custody of the child has child; (b) then, the agreement of the spouse of the parent with custody of the child; and (c) finally, the agreement of the parent not remarriedhaving custody of the child. However, if there is a court decree which establishes a parent’s financial responsibility for the child’s health care expenses, the benefits of a plan the agreement which covers the child as a Dependent of that parent shall be determined first. This paragraph does not apply with respect to any Benefit Period during which any benefits are actually paid or provided before the parent with custody entity obligated to pay or to provide benefits under that parent’s agreement has actual knowledge of the child will be determined before the court decree. iv) The benefits of the agreement covering the person as an employee other than a plan which covers the child laid-off or retired employee or as a Dependent of the parent without custody; and b) When the parents are divorced and the parent with custody of the child has remarried, the benefits of a plan which covers the child as a Dependent of the parent with custody such person shall be determined before the benefits of a plan which covers that child as a Dependent of the stepparent, and the benefits of a plan which covers that child as a Dependent of the stepparent will be determined before the benefits of a plan which covers that child as a Dependent of the parent without custody. Notwithstanding items a) and b) above, if there is a court decree which would otherwise establish financial responsibility for the health care expenses of the child, the benefits of a plan which covers the child as a Dependent of the parent with such financial responsibility shall be determined before the benefits of any other plan which covers the child as a Dependent. iii. When rules i. and ii. do not establish an order of benefit determination, the benefits of a plan which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the benefits of a plan which has covered such person the shorter period of time, provided that: a) The benefits of a plan agreement covering the person as a laid laid-off or retired employee, employee or Dependent of such person shall be determined after the benefits of any other plan covering such person as an employee, other than a laid off or retired employee, or Dependent of such person; and b) . If either plan the Other Agreement does not have a this provision regarding laid laid-off or retired employeesemployees and, which results in each plan determining its benefits after as a result, the otheragreements do not agree on the order of benefits, then the provisions of a) of this subsection shall not applyrule is disregarded. iv. v) If none of the above rules determines the order of benefits, the benefits of the plan agreement which has covered an employee, Member or Subscriber the person for the longer longest period of time shall be determined before those of the plan which covered that person for the shorter time periodfirst. e. When this provision operates to reduce If an Other Agreement does not contain provisions establishing the total amount same order of benefits otherwise to be provided to a person covered under the Agreement during any claim benefit determination periodrules, the reasonable cash value of each benefit benefits under that would agreement will be provided in determined before the absence of benefits under this provision shall be reduced proportionately and such reduced amount shall be charged against any applicable benefit limit of the Agreement.

Effect on Benefits. a. This provision shall apply in determining determination of the benefits for as to a Member covered under the Agreement this Plan for a particular claim determination period any Claim Determination Period, if, for the allowable expenses Allowable Expenses incurred by the Member as to such person during such period, the sum of: i. The reasonable cash value of the benefits that would be provided payable under the Agreement this Plan in the absence of this provision, and ii. The benefits that would be payable under all other plans Plans in the absence therein or of provisions of similar purpose to this provision would exceed such allowable expensesAllowable Expenses. b. As to any claim determination period Claim Determination Period with respect to which this provision is applicable, the reasonable cash value of the benefits provided that would be payable under the Agreement this Plan in the absence of this provision for the allowable expenses Allowable Expenses incurred as to such person during such claim determination period Claim Determination Period shall be reduced to the extent necessary so that the sum of the reasonable cash value of benefits and all such reduced benefits payable for such allowable expenses Allowable Expenses under all other plansPlans, except as provided in subparagraph c. item (c) of this section, Section 3 shall not exceed the total of such allowable expensesAllowable Expenses. Benefits payable under another plan Plan include the benefits that would have been payable had a claim been duly made therefor. In determining liability under this paragraph, GHC is not required, and will not take into consideration, Deductibles, Copayments or other Cost Share provisions. c. If another plan which If: i. Another Plan that is involved in subparagraph b. item (b) of this section Section 3 and which that contains a provision coordinating its benefits with those of the Agreement this Plan would, according to its rules, determine its benefits after the benefits of this plan Plan have been determined; and the , and ii. The rules set forth in subparagraph d. item (e)(iii) of this section Section 3 would require the Agreement this Plan to determine its benefits before such other planPlan, then the benefits of such other plan Plan will be ignored for the purposes of determining the benefits under the Agreementthis Plan. d. If another Plan that is involved in item (b) of this Section 3 does not contain a provision coordinating its benefits with those of this Plan, then the benefits of such other Plan shall be determined before the benefits of this Plan. e. For the purposes purpose of subparagraph c. item (c) of this sectionSection 3, the rules establishing the order of benefit determination are: i. The benefits of a plan which Plan that covers the person on whose expenses a claim is to be based other than as a Subscriber Dependent shall be determined before the benefits of a plan which Plan that covers such person as a Dependent.; ii. If (A) Except for cases of a person for whom claim is made as a Dependent is covered under both parents' medical plansChild whose parents are separated or divorced, the benefits of a plan that covers the plan person on whose expenses claim is based as a Dependent of the parent a person whose birthdaydate of birth, excluding year of birth, occurs earlier in a calendar year, falls earlier shall be determined before the benefits of a Plan that covers such person as a Dependent of a person whose date of birth, excluding year of birth, occurs later in a calendar year. If the other Plan does not have the provisions of this paragraph (ii) (A) regarding Dependents, which results either in each Plan determining its benefits before the other or in each Plan determining its benefits after the other, the provisions of this paragraph (ii) (A) shall not apply, and the rule set forth in the calendar year are determined before those Plan that does not have the provisions of this paragraph ii (A) shall determine the plan order of benefits; (B) In the case of a parent person for whom claim is made as a Dependent Child whose birthday, excluding year, falls later in the calendar year. a) When the parents are separated or divorced and the parent with custody of the child Child has not remarried, the benefits of a plan which Plan that covers the child Child as a Dependent of the parent with custody of the child Child will be determined before the benefits of a plan which Plan that covers the child Child as a Dependent of the parent without custody; and. b(C) When In the case of a person for whom claim is made as a Dependent Child whose parents are divorced and the parent with custody of the child Child has remarried, the benefits of a plan which Plan that covers the child Child as a Dependent of the parent with custody shall be determined before the benefits of a plan which Plan that covers that child Child as a Dependent of the stepparent, and the benefits of a plan which Plan that covers that child Child as a Dependent of the stepparent will be determined before the benefits of a plan which Plan that covers that child Child as a Dependent of the parent without custody. Notwithstanding items a. (D) and b) aboveIn the case of a person for whom claim is made as a Dependent child whose parents are separated or divorced, if where there is a court decree which that would otherwise establish financial responsibility for the medical, dental or other health care expenses of with respect to the childChild, then, notwithstanding paragraphs (B) and (C) above, the benefits of a plan which Plan that covers the child Child as a Dependent of the parent with such financial responsibility shall be determined before the benefits of any other plan which Plan that covers the child Child as a DependentDependent Child. iii. When rules i. rule(s) (i) and (ii. ) as set out above do not establish an order of benefit determination, the benefits of a plan which Plan that has covered the such person on whose expenses claim is based for the longer period of time shall be determined before the benefits of a plan which Plan that has covered such person the shorter period of time, provided that: a(A) The benefits of a plan Plan covering the person as an employee other than a laid laid-off or retired employee, or as a Dependent of such person a laid-off or retired employee, shall be determined after before the benefits of any other plan Plan covering such person as an employee, other than a laid laid-off or retired employee, or as a Dependent of such persona laid-off or retired employee; and b(B) If either plan Plan does not have a provision regarding laid laid-off or retired employees, which results in each plan Plan determining its benefits after the other, then the provisions of a(A) of this subsection above shall not apply. iv. If none of the above rules determines the order of benefits, the benefits of the plan which covered an employee, Member or Subscriber for the longer period of time shall be determined before those of the plan which covered that person for the shorter time period. e. f. When this provision operates to reduce the total amount of benefits otherwise to be provided payable as to a person covered under the Agreement this Plan during any claim determination periodClaim Determination Period, the reasonable cash value of each benefit that would be provided payable in the absence of this provision shall be reduced proportionately and such reduced amount shall be charged against any applicable benefit limit of the Agreementthis Plan.

Effect on Benefits. a. This provision shall apply in determining the benefits for as to a Member covered under the Agreement this Plan for a particular claim determination period any Claim Determination Period, if, for the allowable expenses Allowable Expenses incurred by the Member as to such person during such period, the sum of: i. The reasonable cash value of the benefits that would be provided payable under the Agreement this Plan in the absence of this provision, and ii. The the benefits that would be payable under all other plans Plans in the absence therein or of provisions of similar purpose to this provision would exceed such allowable expensesAllowable Expenses. b. As to any claim determination period Claim Determination Period with respect to which this provision is applicable, the reasonable cash value of the benefits provided that would be payable under the Agreement this Plan in the absence of this provision for the allowable expenses Allowable Expenses incurred as to such person during such claim determination period Claim Determination Period shall be reduced to the extent necessary so that the sum of the reasonable cash value of benefits and all such reduced benefits payable for such allowable expenses Allowable Expenses under all other plansPlans, except as provided in subparagraph c. item (c) of this section, Section 7.3 shall not exceed the total of such allowable expensesAllowable Expenses. Benefits payable under another plan Plan include the benefits that would have been payable had a claim been duly made therefor. In determining liability under this paragraph, GHC is not required, and will not take into consideration, Deductibles, Copayments or other Cost Share provisions. c. If another plan which If: i. Another Plan that is involved in subparagraph b. item (b) of this section Section 7.3 and which that contains a provision coordinating its benefits with those of the Agreement this Plan would, according to its rules, determine its benefits after the benefits of this plan Plan have been determined; and the , and ii. The rules set forth in subparagraph d. item (b) of this section Section 7.3 would require the Agreement this Plan to determine its benefits before such other planPlan, then the benefits of such other plan Plan will be ignored for the purposes of determining the benefits under the Agreementthis Plan. d. For the purposes of subparagraph c. of this section, the rules establishing the order of benefit determination are: i. The benefits of a plan which covers the person on whose expenses a claim is based as a Subscriber shall be determined before the benefits of a plan which covers such person as a Dependent. ii. If a Dependent is covered under both parents' medical plans, the benefits of the plan of the parent whose birthday, excluding year, falls earlier in the calendar year are determined before those of the plan of a parent whose birthday, excluding year, falls later in the calendar year. a) When the parents are separated or divorced and the parent with custody of the child has not remarried, the benefits of a plan which covers the child as a Dependent of the parent with custody of the child will be determined before the benefits of a plan which covers the child as a Dependent of the parent without custody; and b) When the parents are divorced and the parent with custody of the child has remarried, the benefits of a plan which covers the child as a Dependent of the parent with custody shall be determined before the benefits of a plan which covers that child as a Dependent of the stepparent, and the benefits of a plan which covers that child as a Dependent of the stepparent will be determined before the benefits of a plan which covers that child as a Dependent of the parent without custody. Notwithstanding items a) and b) above, if there is a court decree which would otherwise establish financial responsibility for the health care expenses of the child, the benefits of a plan which covers the child as a Dependent of the parent with such financial responsibility shall be determined before the benefits of any other plan which covers the child as a Dependent. iii. When rules i. and ii. do not establish an order of benefit determination, the benefits of a plan which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the benefits of a plan which has covered such person the shorter period of time, provided that: a) The benefits of a plan covering the person as a laid off or retired employee, or Dependent of such person shall be determined after the benefits of any other plan covering such person as an employee, other than a laid off or retired employee, or Dependent of such person; and b) If either plan does not have a provision regarding laid off or retired employees, which results in each plan determining its benefits after the other, then the provisions of a) of this subsection shall not apply. iv. If none of the above rules determines the order of benefits, the benefits of the plan which covered an employee, Member or Subscriber for the longer period of time shall be determined before those of the plan which covered that person for the shorter time period. e. When this provision operates to reduce the total amount of benefits otherwise to be provided to a person covered under the Agreement during any claim determination period, the reasonable cash value of each benefit that would be provided in the absence of this provision shall be reduced proportionately and such reduced amount shall be charged against any applicable benefit limit of the Agreement.