Third Party Liability & Coordination of Benefits Sample Clauses

Third Party Liability & Coordination of Benefits. (a) EOHHS is responsible for adjudicating the Cost Share Obligations under the State Plan. The MA Health Plan will adjudicate and pay claims in accordance with Medicare rules and regulations and provide evidence of payment information to providers, which identifies coordination amounts for their claim submission to the State Plan. Pursuant to the State Plan, EOHHS will remain financially responsible for Cost-Sharing Obligations and Medicaid Benefits for Dual Eligible Members. EOHHS may have financial responsibility for Medicare Part A and/or Part B premiums for Dual Eligible Member. EOHHS is not responsible for payment of Medicare Advantage premiums for mandatory or optional Supplement Benefits, unless specifically prescribed in the State Plan.
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Third Party Liability & Coordination of Benefits a) The MA Health Plan will be the payer of all Medicare cost sharing that the Department would otherwise pay. b) The Department may have financial responsibility for Medicare Part A and/or Part B premiums for certain Dual Eligible Members as described in the State Plan. The Department shall identify and pay those premiums for Dual Eligible Members.
Sample 1Sample 2
Third Party Liability & Coordination of Benefits. (a) The Department or Medicaid MCO is responsible for adjudicating the Cost Share Obligations under the State Plan. (b) The MA Health Plan will adjudicate and pay claims in accordance with Medicare rules and regulations and provide evidence of payment information to providers, which will identify coordination amounts for their claim submission to the State Plan. (c) Pursuant to the State Plan, The Department or Medicaid MCO will remain financially responsible for Cost-Sharing Obligations and Medicaid Benefits for Dual Eligibles who are Members of MA Health Plan’s SNP(s). The Department or Medicaid MCO may have financial responsibility for Medicare Part A and/or Part B premiums for Dual Eligibles. The Department or Medicaid MCO is not responsible for payment of Medicare Advantage premiums for mandatory or optional Supplement Benefits, unless specifically prescribed in the State Plan.
Sample 1
Third Party Liability & Coordination of Benefits. (a) The Department is responsible for adjudicating the Cost Share under the State Plan. (b) The MA Health Plan will adjudicate and pay claims in accordance with Medicare rules and regulations and provide Evidence of Payment information to providers, which identifies coordination amounts for their claim submission to the State Plan. (c) Pursuant to the State Plan, the Department will remain financially responsible for Cost- Sharing for Full Benefit Dual Eligibles and QMB who are members of MA Health Plan’s SNP(s). The Department may have financial responsibility for Medicare Part A and/or Part B premiums for other categories of Dual Eligibles (as defined in Article II) in the MA Health Plan’s SNP as described in the State Plan.
Sample 1
Third Party Liability & Coordination of Benefits. (a) The Department is responsible for adjudicating the Dual Eligible member’s cost share under the State Plan. (b) The D-SNP will adjudicate and pay claims in accordance with Medicare rules and regulations and provide Evidence of Payment information to providers, which identifies coordination amounts for their claim submission to the State Plan. (c) Pursuant to the State Plan, the Department will remain financially responsible for cost- sharing for Full Benefit Dual Eligible members and QMB Dual Eligible members who are members of the D-SNP. The Department may have financial responsibility for Medicare Part A and/or Part B premiums for other categories of Dual Eligible members (as defined in Article II) in the Contractor’s D-SNP as described in the State Plan.
Sample 1

Related to Third Party Liability & Coordination of Benefits

  • Coordination of Benefits i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits under any other group or pre-paid plan or insurance plan designed to fully integrate with other plans. If this plan is the “primary” plan, Delta Dental will not reduce Benefits. If this plan is the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental determine which Plan is the “primary” plan? 1) The plan covering the Enrollee as an employee is primary over a plan covering the Enrollee as a dependent. 2) The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; but b) if both parents have the same birthday, the benefits of the plan covering one parent longer are determined before those of the plan covering the other parent for a shorter period of time. c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parents, the plan covering the Enrollee as a dependent of the parent with legal custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent of the parent with such financial responsibility will be determined before the benefits of any other policy covering the child as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither laid-off nor retired are determined before those of a plan covering that insured person as a laid-off or retired employee. The same would hold true if an insured person is a dependent of a person covered as a retiree or an 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 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the following will be the order of benefit determination. a) First, the benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not have the rule described above, and if, as a result, the plans do not agree on the order of benefits, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot be made in accordance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only plan.

  • Coordination of Benefits and Subrogation IPA and HMO shall establish and implement a system for coordination of benefits and subrogation, in accordance with those rules established under the HMO's policies and procedures and applicable federal and state laws. If known to IPA, IPA shall identify and inform HMO of Members for whom coordination of benefits and subrogation opportunities exist. HMO hereby authorizes IPA to seek payment, on a fee-for service basis or otherwise, from any insurance carrier, organization, or government agency which is primarily responsible for the payment or provision of medical services provided by IPA under this Agreement which can be recovered by reason of coordination of benefits, motor vehicle injury, worker's compensation, temporary disability, occupational disease, or similar exclusionary or limiting provisions, to the extent authorized by the applicable and not otherwise prohibited by law.

  • Loss of Benefits Employees who are separated from the service by a discharge under other than honorable conditions, bad conduct, or dishonorable discharge shall not be entitled to any of the benefits of Section 3 through Section 9 of the Article (relating to military leaves without pay) except such vested rights as they may have acquired thereto by virtue of payments made into their retirement accounts.

  • Mitigation; Exclusivity of Benefits (a) The Executive shall not be required to mitigate the amount of any benefits hereunder by seeking other employment or otherwise, nor shall the amount of any such benefits be reduced by any compensation earned by the Executive as a result of employment by another employer after the Date of Termination or otherwise. (b) The specific arrangements referred to herein are not intended to exclude any other benefits which may be available to the Executive upon a termination of employment with the Employers pursuant to employee benefit plans of the Employers or otherwise.

  • Coordination of Services Consultant agrees to work closely with City staff in the performance of Services and shall be available to City’s staff, consultants and other staff at all reasonable times.

  • Termination of Benefits Except as provided in Section 2 above or as may be required by law, Executive’s participation in all employee benefit (pension and welfare) and compensation plans of the Company shall cease as of the Termination Date. Nothing contained herein shall limit or otherwise impair Executive’s right to receive pension or similar benefit payments that are vested as of the Termination Date under any applicable tax-qualified pension or other plans, pursuant to the terms of the applicable plan.

  • Files Management and Record Retention relating to Grantee and Administration of this Agreement a. The Grantee shall maintain books, records, and documents in accordance with generally accepted accounting procedures and practices which sufficiently and properly reflect all expenditures of funds provided by Florida Housing under this Agreement. b. Contents of the Files: Grantee must maintain files containing documentation to verify all funds awarded to Grantee in connection with this Agreement, as well as reports, records, documents, papers, letters, computer files, or other material received, generated, maintained or filed by Grantee in connection with this Agreement. Grantee must also keep files, records, computer files, and reports that reflect any compensation it receives or will receive in connection with this Agreement.

  • Payment of Benefits All or part of the contract benefits may be paid under one or more of the following: - a variable payment plan; - a fixed payment plan; or - in cash. The provisions and rate for variable and fixed payment plans are described in Section 11. Contract benefits may not be placed under a payment plan unless the plan would provide to each beneficiary a monthly income the initial amount of which is at least the minimum payment amount shown on page 4. A Withdrawal Charge will be deducted from contract benefits before their payment under certain conditions described in Section 7.3.

  • Maintenance of Benefits With respect to negotiable wages, hours and working conditions not covered by this Agreement, the State agrees to make no changes without appropriate prior consultation and negotiations with the Association unless such change is made to comply with law, and existing regulations, Personnel Rules, written Policies and Procedures, General Orders, General Operating Procedure, or Standard Operating Procedure.

  • Duplication of Benefits Grantee shall not carry out any of the activities under this Agreement in a manner that results in a prohibited duplication of benefits as defined by Section 312 of the Xxxxxx X. Xxxxxxxx Disaster Relief and Emergency Assistance Act (42 U.S.C. 5155) and in accordance with Section 1210 of the Disaster Recovery Reform Act of 2018 (division D of Public Law 115-254; 132 Stat. 3442), which amended section 312 of the Xxxxxx X. Xxxxxxxx Disaster Relief and Emergency Assistance Act (42 U.S.C. 5155). In consideration of Grantee’s receipt or the commitment of CRF funds by Florida Housing, Grantee hereby assigns to Florida Housing all of Grantee’s future rights to reimbursement and all payments received from any grant, subsidized loan or any other reimbursement or relief program related to the basis of the calculation of the portion of the funds committed to the Grantee under this Agreement and determined to be a Duplication of Benefits (DOB). Any such funds received by the Grantee shall be referred to herein as “additional funds.” Grantee agrees to immediately notify Florida Housing of the source and receipt of additional funds received by the Grantee that are determined to be a DOB. Grantee agrees to reimburse Florida Housing for any additional funds received by Grantee if such additional funds are determined to be a DOB by Florida Housing, the Federal awarding agency or an auditing agency.

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