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Common use of Rules Clause in Contracts

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows: (1) For a dependent child whose parents are married or are living together: SAMPLE (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse does, that parent’s Spouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) a court decree states the parents have joint custody without specifying one parent has responsibility for the health care expenses or coverage of the dependent child. (b) If there is no court decree setting out the responsibility i) The Plan of the parent with custody of the child; ii) The Plan of the Spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 4 contracts

Samples: Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement, Individual Enrollment Agreement for a Qualified Health Plan

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Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows: (1) For a dependent child whose parents are married or are living together: SAMPLE: (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 the year; butbut SAMPLE (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse does, that parent’s Spouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) a court decree states the parents have joint custody without specifying one parent has responsibility for the health care expenses or coverage of the dependent child. (b) If there is no court decree setting out the responsibilityresponsibility for the child’s health care expenses or health care coverage, the order of benefits for the dependent child are as follows: i) The Plan of the parent with custody of the child; ii) The Plan of the Spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE. c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.. SAMPLE

Appears in 4 contracts

Samples: Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement for a Qualified Health Plan

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent.. SAMPLE b) Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows: (1) For a dependent child whose parents are married or are living together: SAMPLE: (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse spouse does, that parent’s Spousespouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states that both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) 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 dependent child. (b) If there is no court decree setting out the responsibilityresponsibility for the child’s health care expenses or health care coverage, the order of benefits for the dependent child are as follows: i) The Plan of the parent with custody of the child; ii) The Plan of the Spouse spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse spouse of the parent who does not have custody of the child.. SAMPLE (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE. c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 3 contracts

Samples: Individual Enrollment Agreement, Individual Enrollment Agreement, Individual Enrollment Agreement for a Qualified Health Plan

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows: (1) For a dependent child whose parents are married or are living together: SAMPLE: (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse spouse does, that parent’s Spousespouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states that both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) 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 dependent child. (b) If there is no court decree setting out the responsibility i) The Plan of the parent with custody of responsibility for the child; ii) The Plan of the Spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child’s health care expenses or health care coverage, the order of benefits shall be determined, as applicable, under for the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the dependent child. SAMPLE c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 3 contracts

Samples: In Network Group Contract, In Network Group Contract, In Network Group Contract

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows: (1) For a dependent child whose parents are married or are living together: SAMPLE: (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse does, that parent’s Spouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) a court decree states the parents have joint custody without specifying one parent has responsibility for the health care expenses or coverage of the dependent child. (b) If there is no court decree setting out the responsibility i) The Plan of the parent with custody of the child; ii) The Plan of the Spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE. c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 2 contracts

Samples: Individual Enrollment Agreement, Individual Enrollment Agreement

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules rules, which applies:. a(i) Non-dependentNondependent/dependentDependent. The benefits of the Plan which that covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which that covers the person as a dependent; except if the person is also a Medicare beneficiarydependent of an employee, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is:member or subscriber. (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. bii) Dependent child covered by more than one PlanChild/Parents Not Separated or Divorced. Unless there is a court decree stating otherwiseExcept as stated in subparagraph (iii) (C) below, when this CareFirst BlueChoice This Plan and another Plan cover the same child as a dependentdependent of different persons, the order of benefits shall be determined as followscalled “parents”: (1A) For a dependent child whose parents are married or are living together: SAMPLE (a) The the benefits of the Plan of the parent whose birthday falls earlier in a the calendar year are determined before those of the Plan of the parent whose birthday falls later in the calendar year; but (bB) If if both parents have the same birthday, the benefits of the Plan that covered one the parent longer are determined before those of the Plan that covered the other parent for parent. However, if the other Plan does not have the rule described in (A) but instead has a shorter period rule based upon the gender of timethe parent, and if, as a result, the Plans do not agree on the order of benefits, the rule in the other Plan shall determine the order of benefits. (2iii) For Dependent Child/Separated or Divorced Parents. If two or more Plans cover a person as a dependent child whose parents of divorced or separated parents, benefits for the child are separated, divorced, or are not living togetherdetermined in this order: (aA) If first, the Plan of the parent with custody of the child; (B) then, the Plan of the spouse of the parent with custody of the child; and (C) finally, the Plan of the parent not having custody of the child. Also, if the specific terms of a court decree state that the parents have joint custody of the child and do not specify that one parent has responsibility for the child’s health care expenses or if the court decree states that both parents shall be responsible for the health care needs of the child but gives physical custody of the child to one parent and the entities obligated to pay or provide benefits of the respective parents’ Plans have actual knowledge of those terms, benefits for the dependent child shall be determined according to Paragraph 6.3(b)(ii). However, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the a child, and the entity obligated to pay or provide the benefits Benefits of the Plan of that parent has actual knowledge of those terms, the benefits Benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse does, that parent’s Spouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered Claim Determination Period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) a court decree states the parents have joint custody without specifying one parent has responsibility for the health care expenses or coverage of the dependent childknowledge. (b) If there is no court decree setting out the responsibility i) The Plan of the parent with custody of the child; ii) The Plan of the Spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE c) Active/inactive employeeInactive Employee. The benefit benefits of a Plan which covers cover a person as an employee who is neither laid off nor retired is or as that employee's dependent(s) are determined before those of a Plan that which covers that person as a laid off or retired employee or as that employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee’s dependent. If the other Plan does not have this rule, rule and if, as a result, the Plans do not agree on the order of benefits, this rule (iv) is ignored.

Appears in 2 contracts

Samples: Master Group Ppo Contract, Master Group Contract

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows:: SAMPLE (1) For a dependent child whose parents are married or are living together: SAMPLE: (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse spouse does, that parent’s Spousespouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states that both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) 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 dependent child. (b) If there is no court decree setting out the responsibilityresponsibility for the child’s health care expenses or health care coverage, the order of benefits for the dependent child are as follows: i) The Plan of the parent with custody of the child; ii) The Plan of the Spouse spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 2 contracts

Samples: Individual Enrollment Agreement for a Qualified Health Plan, Individual Enrollment Agreement for a Qualified Health Plan

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows: (1) For a dependent child whose parents are married or are living together: SAMPLE: (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse does, that parent’s Spouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) a court decree states the parents have joint custody without specifying one parent has responsibility for the health care expenses or coverage of the dependent child. (b) If there is no court decree setting out the responsibilityresponsibility for the child’s health care expenses or health care coverage, the order of benefits for the dependent child are as follows: i) The Plan of the parent with custody of the child; ii) The Plan of the Spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE. c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 2 contracts

Samples: Individual Enrollment Agreement, Individual Enrollment Agreement

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) a. Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., e.g. retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependentDependent. b) b. Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependentDependent, the order of benefits shall be determined as follows: (1) For a dependent Dependent child whose parents are married or are living together: SAMPLE: (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. This rule described in 1) also shall apply if: (i) a court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage or (ii) 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 dependent child. (2) For a dependent Dependent child whose parents are separated, divorced, or are is not living together: (a) If the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s 's health care expenses, but the parent’s 's Spouse does, that parent’s 's Spouse’s 's plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has that actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) a court decree states the parents have joint custody without specifying one parent has responsibility for the health care expenses or coverage of the dependent child. (b) If there is no court decree setting out the responsibilityresponsibility for the child's health care expenses or health care coverage, the order of benefits for the dependent child are as follows: (i) The Plan of the parent with custody of the child; (ii) The Plan of the Spouse of the parent with the custody of the child; (iii) The Plan of the parent not having custody of the child; and then (iv) The Plan of the Spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 2 contracts

Samples: Member Contract, Member Contract

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows: (1) For a dependent child whose parents are married or are living together: SAMPLESample (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse does, that parent’s Spouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) a court decree states the parents have joint custody without specifying one parent has responsibility for the health care expenses or coverage of the dependent child. (b) If there is no court decree setting out the responsibility i) The Plan of the parent with custody of the child; ii) The Plan of the Spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLESample c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 1 contract

Samples: Individual Enrollment Agreement for a Qualified Health Plan

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows:: SAMPLE (1) For a dependent child whose parents are married or are living together: SAMPLE: (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s 's health care expenses, but the parent’s Spouse 's spouse does, that parent’s Spouse’s 's spouse's plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states that both parents are responsible for the dependent child’s 's health care expenses or health care coverage, or ii) 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 dependent child. (b) If there is no court decree setting out the responsibility i) The Plan of the parent with custody of the child; ii) The Plan of the Spouse spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE (4) For a dependent child who has coverage under either or both parents' plans and also has his or her own coverage as a dependent under a spouse's plan, the rule in Paragraph C.2.e) below 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 C.2.b) (1) to the dependent child's parent(s) and the dependent's spouse. c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 1 contract

Samples: Student Health Plan Individual Enrollment Agreement

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Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules rules, which applies:. a(i) Non-dependentNondependent/dependentDependent. The benefits of the Plan which that covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which that covers the person as a dependent; except if the person is also a Medicare beneficiarydependent of an employee, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is:member or subscriber. (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. bii) Dependent child covered by more than one PlanChild/Parents Not Separated or Divorced. Unless there is a court decree stating otherwiseExcept as stated in subparagraph (iii) (C) below, when this CareFirst BlueChoice This Plan and another Plan cover the same child as a dependentdependent of different persons, the order of benefits shall be determined as followscalled “parents”: (1A) For a dependent child whose parents are married or are living together: SAMPLE (a) The the benefits of the Plan of the parent whose birthday falls earlier in a the calendar year are determined before those of the Plan of the parent whose birthday falls later in the calendar year; but (bB) If if both parents have the same birthday, the benefits of the Plan that covered one the parent longer are determined before those of the Plan that covered the other parent for parent. However, if the other Plan does not have the rule described in (A) but instead has a shorter period rule based upon the gender of timethe parent, and if, as a result, the Plans do not agree on the order of benefits, the rule in the other Plan shall determine the order of benefits. (2iii) For Dependent Child/Separated or Divorced Parents. If two or more Plans cover a person as a dependent child whose parents of divorced or separated parents, benefits for the child are separated, divorced, or are not living togetherdetermined in this order: (aA) If first, the Plan of the parent with custody of the child; (B) then, the Plan of the spouse of the parent with custody of the child; and (C) finally, the Plan of the parent not having custody of the child. Also, if the specific terms of a court decree state that the parents have joint custody of the child and do not specify that one parent has responsibility for the child’s health care expenses or if the court decree states that both parents shall be responsible for the health care needs of the child but gives physical custody of the child to one parent and the entities obligated to pay or provide benefits of the respective parents’ Plans have actual knowledge of those terms, benefits for the dependent child shall be determined according to Paragraph 6.3(b)(ii). However, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the a child, and the entity obligated to pay or provide the benefits Benefits of the Plan of that parent has actual knowledge of those terms, the benefits Benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse does, that parent’s Spouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered Claim Determination Period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) a court decree states the parents have joint custody without specifying one parent has responsibility for the health care expenses or coverage of the dependent childknowledge. (b) If there is no court decree setting out the responsibility i) The Plan of the parent with custody of the child; ii) The Plan of the Spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE c) Active/inactive employeeInactive Employee. The benefit benefits of a Plan which covers cover a person as an employee who is neither laid off nor retired is or as that employee's dependent(s) are determined before those of a Plan that which covers that person as a laid off or retired employee or as that employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee’s dependent. If the other Plan does not have this rule, rule and if, as a result, the Plans do not agree on the order of benefits, this rule (iv) is ignored. (v) Continuation Coverage. (A) If a person has continuation coverage under federal or state law and is also covered under another Plan, the following shall determine the order of benefits: 1. First, the benefits of a Plan covering the employee, member, or subscriber or dependent of an employee, member, or subscriber. 2. Second, the benefits under the continuation coverage. (B) If the other Plan does not have the rule described in subparagraph (A), and if as a result, the Plans do not agree on the order of benefits, this paragraph (v) is ignored.

Appears in 1 contract

Samples: Master Group Ppo Contract

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows:: SAMPLE (1) For a dependent child whose parents are married or are living together: SAMPLE: (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse does, that parent’s Spouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) a court decree states the parents have joint custody without specifying one parent has responsibility for the health care expenses or coverage of the dependent child. (b) If there is no court decree setting out the responsibility i) The Plan of the parent with custody of the child; ii) The Plan of the Spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 1 contract

Samples: Individual Enrollment Agreement for a Qualified Health Plan

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows: (1) For a dependent child whose parents are married or are living together: SAMPLE: (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s 's health care expenses, but the parent’s Spouse 's spouse does, that parent’s Spouse’s 's spouse's plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states that both parents are responsible for the dependent child’s 's health care expenses or health care coverage, or ii) 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 dependent child. (b) If there is no court decree setting out the responsibility i) The Plan of the parent with custody of responsibility for the child; ii) The Plan of the Spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child's health care expenses or health care coverage, the order of benefits shall be determined, for the dependent child are as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.follows:

Appears in 1 contract

Samples: Student Health Plan Individual Enrollment Agreement

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules rules, which applies:. a(i) Non-dependentNondependent/dependentDependent. The benefits of the Plan which that covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which that covers the person as a dependent; except if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is:dependentCoonftraanct Requisition Number: CR062000 (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. bii) Dependent child covered by more than one PlanChild/Parents Not Separated or Divorced. Unless there is a court decree stating otherwiseExcept as Contract Number: C031823 Vendor Number: V025357 stated in subparagraph (iii) (C) below, when this CareFirst BlueChoice This Plan and another Plan cover the same child as a dependentdependent of different persons, the order of benefits shall be determined as followscalled “parents”: (1A) For a dependent child whose parents are married or are living together: SAMPLE (a) The the benefits of the Plan of the parent whose birthday falls earlier in a the calendar year are determined before those of the Plan of the parent whose birthday falls later in the calendar year; but (bB) If if both parents have the same birthday, the benefits of the Plan that covered one the parent longer are determined before those of the Plan that covered the other parent for parent. However, if the other Plan does not have the rule described in (A) but instead has a shorter period rule based upon the gender of timethe parent, and if, as a result, the Plans do not agree on the order of benefits, the rule in the other Plan shall determine the order of benefits. (2iii) For Dependent Child/Separated or Divorced Parents. If two or more Plans cover a person as a dependent child whose parents of divorced or separated parents, benefits for the child are separated, divorced, or are not living togetherdetermined in this order: (aA) If first, the Plan of the parent with custody of the child; (B) then, the Plan of the spouse of the parent with custody of the child; and (C) finally, the Plan of the parent not having custody of the child. Also, if the specific terms of a court decree state that the parents have joint custody of the child and do not specify that one parent has responsibility for the child’s health care expenses or if the court decree states that both parents shall be responsible for the health care needs of the child but gives physical custody of the child to one parent and the entities obligated to pay or provide benefits of the respective parents’ Plans have actual knowledge of those terms, benefits for the dependent child shall be determined according to Paragraph 6.3(b)(ii). However, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the a child, and the entity obligated to pay or provide the benefits Benefits of the Plan of that PlaCnonotrfactthRaetquisition Number: CR062000 parent has actual knowledge of those terms, the benefits Benefits of that Plan PCloanntract Number: C031823 are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse does, that parent’s Spouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered Claim Determination Period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: i) a court decree states both parents are responsible for the dependent child’s health care expenses or health care coverage, or ii) a court decree states the parents have joint custody without specifying one parent has responsibility for the health care expenses or coverage of the dependent childknowledge. (b) If there is no court decree setting out the responsibility i) The Plan of the parent with custody of the child; ii) The Plan of the Spouse of the parent with the custody of the child; iii) The Plan of the parent not having custody of the child; and then iv) The Plan of the Spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE c) Active/inactive employeeInactive Employee. The benefit benefits of a Plan which covers cover a person as an employee who is neither laid off nor retired is or as that employee's dependent(s) are determined before those of a Plan that which covers that person as a laid off or retired employee or as that employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee’s dependent. If the other Plan does not have this rule, rule and if, as a result, the Plans do not agree on the order of benefits, this rule (iv) is ignored.

Appears in 1 contract

Samples: Dental Care Benefits Contract

Rules. This CareFirst BlueChoice Evergreen Health Plan determines its order of benefits using the first of the following rules which applies: a) a. Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) : i Secondary to the Plan covering the person as a dependent, and (2) and ii Primary to the Plan covering the person as other than a dependent (e.g., e.g. retired employee), . Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) b. Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Evergreen Health Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows: (1) i For a dependent child whose parents are married or are living together: SAMPLE: (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) . ii For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the that parent’s Spouse spouse does, that parent’s Spousespouse’s plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The rule described in . (1b) above also shall apply if: i) If a court decree states that both parents are responsible for the dependent child’s health care expenses or health care coverage, or iithe provisions of C.2.b.i. of this Section determine the order of benefits. (c) If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of C.2.b.i. of this Section determine the order of benefits. (bd) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (e) If there is no court decree setting out allocating responsibility for the responsibilitychild’s health care expenses or health care coverage, the order of benefits for the child are as follows: (i) The Plan of the parent with custody of the child; ii) I. The Plan of the Spouse spouse of the parent with the custody of the child; iii) II. The Plan of the parent not having custody of the child; and then iv) III. The Plan of the Spouse spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE c) Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 1 contract

Samples: Individual Plan Agreement

Rules. This CareFirst BlueChoice Evergreen Plan determines its order of benefits using the first of the following rules which applies: a) Non-dependenta. Non−dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the Plan covering the person as a dependent, and (2) Primary to the Plan covering the person as other than a dependent (e.g., e.g. retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) b. Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Evergreen Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows: (1) For a dependent child whose parents are married or are living together: SAMPLE: (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 the year; but (b) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) For a dependent child whose parents are separated, divorced, or are not living together: (a) If the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but the parent’s Spouse spouse does, that parent’s Spousespouse’s plan Plan is the primary planPrimary Plan. This paragraph does not apply with respect to any claim for services rendered before the entity has actual knowledge of the terms of the court decree. The This rule described in (1) above also shall apply if: (i) a court decree states that both parents are responsible for the dependent child’s health care expenses or health care coverage, ; or (ii) 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 dependent child. (b) If there is no court decree setting out the responsibilityresponsibility for the child’s health care expenses or health care coverage, the order of benefits for the dependent child are as follows: (i) The Plan of the parent with custody of the child; (ii) The Plan of the Spouse spouse of the parent with the custody of the child; (iii) The Plan of the parent not having custody of the child; and then (iv) The Plan of the Spouse spouse of the parent who does not have custody of the child. (3) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated set forth in (1) and (2) of this paragraph as if those individuals were parents of the child. SAMPLE. c) Active/inactive employeec. Active Employee or Retired or Laid−Off Employee. The benefit of a Plan which covers a person as an active employee who is neither laid off nor retired is determined before those of a Plan the primary plan. The plan covering that covers that same person as a laid off retired or retired employee. The same would hold true if a person is laid−off employee or as a dependent of a person covered as an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. laid−off employee is the secondary plan. d. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 1 contract

Samples: Individual Plan Agreement

Rules. This CareFirst BlueChoice Plan determines its order of benefits using the first of the following rules which applies: a) a. Non-dependent/dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, and the result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) i. Secondary to the Plan covering the person as a dependent, and (2) ii. Primary to the Plan covering the person as other than a dependent (e.g., e.g. retired employee), Then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering the person as other than a dependent. b) b. Dependent child covered by more than one Plan. Unless there is a court decree stating otherwise, when this CareFirst BlueChoice Plan and another Plan cover the same child as a dependent, the order of benefits shall be determined as follows: (1) i. For a dependent child whose parents are married or are living together: SAMPLE: (a1) 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 the year; but (b2) If both parents have the same birthday, the benefits of the Plan that covered one parent longer are determined before those of the Plan that covered the other parent for a shorter period of time. (2) ii. For a dependent child whose parents are separated, divorced, or are not living together: (a1) If the specific terms of a court decree state that one of the parents is responsible for the health care expenses or health care coverage of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. If the parent with responsibility has no health care coverage for the dependent child’s 's health care expenses, but the parent’s Spouse 's spouse does, that parent’s Spouse’s 's spouse's plan is the primary plan. This paragraph does not apply with respect to any claim for services rendered before the entity has that actual knowledge of the terms of the court decree. The rule described in (1) above also shall apply if: (i) a court decree states that both parents are responsible for the dependent child’s 's health care expenses or health care coverage, coverage or (ii) 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 dependent child. (b2) If there is no court decree setting out the responsibilityresponsibility for the child's health care expenses or health care coverage, the order of benefits for the dependent child are as follows: ia) The Plan of the parent with custody of the child; iib) The Plan of the Spouse spouse of the parent with the custody of the child; iiic) The Plan of the parent not having custody of the child; and then ivd) The Plan of the Spouse spouse of the parent who does not have custody of the child. (3) iii. For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under the rules stated set forth in (1) and (2) of this paragraph as if those individuals were where parents of the child. SAMPLE. c) c. Active/inactive employee. The benefit of a Plan which covers a person as an employee who is neither laid off nor retired is determined before those of a Plan that which covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as a retiree and an employee who is neither laid off nor retired or a person covered as a laid off or retired employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule is ignored.

Appears in 1 contract

Samples: Member Contract

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