UFCW Midwest - Midwest Health and Pension Funds

United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

Coordination of Benefits

Some plans do not include every benefit mentioned. Refer to your plan booklet to verify which benefits are included in your plan.

Purpose of Coordination of Benefits (COB)

A COB provision ensures that you receive all the benefits to which you are entitled. If you or an eligible dependent have a claim that is covered by two or more group medical plans, one plan—the primary plan—pays its benefits first, regardless of the amounts payable under any other plan. The other plans—the secondary plan—will adjust their benefit payments so that the total benefits paid to you do not exceed 100% of the charge for covered expenses.

Group Medical Plan

A group medical plan is one that covers medical expenses provided by:

  • Group insurance.
  • Group BlueCross, group BlueShield or other prepayment coverage on a group basis, including health maintenance organizations (HMOs).
  • Coverage under labor-management trusteed plans, union welfare plans, employer organization plans or employee benefit organization plans.
  • Coverage under governmental programs or coverage required or provided by any statute.
  • School or association excess plans.
  • Other arrangements of covered or self-covered group coverage.
  • Plans for which any employer directly or indirectly has made contributions or payroll-deductions.

Complying with the COB Provision

It is easy to comply with the COB provision—when you file a claim form, be sure to fill out the section that asks if you or the patient has other health coverage. If this Plan is primary, we will pay our benefits. If we are secondary, the Claims Department will use the benefit explanations from the other health plan to determine the balance that is payable to you.

Determining Which Plan is Primary

A plan without a COB provision is always the primary plan.

If a plan has COB provisions that conflict with the COB provisions of this Plan, the dispute will be resolved by having each plan pay 50% of the allowable charges.

Generally, if the other plans have COB provisions, the following rules apply:

  • The plan that covers the person as a non-dependent, such as an employee, member, subscriber or retiree, pays before a plan that covers a person as a dependent.
  • The plan that covers a person as an active employee shall pay its benefits before a plan which covers the person as a laid-off or retired employee.
  • If this Plan covers the person under the COBRA provisions, it pays second.
  • When the person is a dependent of parents who are not separated or divorced and both parents have medical coverage for their eligible dependent children, the plan of the parent whose birthday comes earlier in the calendar year will be considered the primary plan. If both parents’ birthdays are on the same day, the plan covering the parent for the longer period of time will be primary. If one plan uses the male/female rule and the other plan uses the birthday rule, the plan using the male/female rule pays first.
    • If no court decree exists and the parent with custody has not remarried, the plan of the parent with custody is primary.
    • If the parents have joint custody and the divorce decree does not specify that one parent has responsibility for coverage, the birthday rule applies.
    • If no court decree exists and the parent with custody remarries, the plan of the parent with custody pays first, the plan of the spouse of the custodial parent pays second, and the plan of the parent without custody pays last.
    • If the parents are separated or divorced, their plans will pay medical benefits for eligible dependents as follows:
    • If a court order states that one of the parents is responsible for the child’s health care expenses, the health plan covering that parent is primary, provided the plan has knowledge of the court decree.
  • If a person is covered by two plans as a non-dependent, the plan under which the person works the greater number of hours pays first.
  • If a person is covered by a plan as a non-dependent and that other plan provides that the customary coordination of benefits rules for health insurance are inapplicable or a reduced level of coverage is applicable because the person in question is covered as a dependent under this Plan, then this Plan shall coordinate benefits as if the other plan had paid based upon the customary coordination of benefits rules for health insurance and the other plan’s regular plan of benefits that would have applied to the individual but for the reduction in benefits due to coverage under this Plan. If the Plan cannot disregard the other plan’s rule that seeks to avoid the result under customary coordination of benefits rules for health insurance and/or that seeks to apply a reduced level of benefits because of the individual’s coverage as a dependent under this Plan, then this Plan will limit such individual’s coverage under this Plan to a maximum benefit for claims incurred in a calendar year to $1,000 per calendar year.
  • If none of the above rules apply in determining which plan pays first, then the plan covering the person for the longer continuous period of time shall be primary.
  • If any plan has a provision which results in lower benefits being paid because of the existence of this Plan, this Plan shall pay as if the other plan had paid its regular benefits which would apply to a covered person based upon the customary coordination of benefits rules.

Primary Plan Procedures Must Be Followed

If you or your eligible dependent are covered under another plan that has primary responsibility for expenses, you must follow all required procedures to obtain treatment and to qualify for all benefits available under your other plan. If, for any reason, you do not follow your primary plan’s procedures, this Plan limits coverage to expenses, if any, which would have been payable had the necessary procedures been followed.

Expenses incurred because of a primary plan’s refusal for any reason to refer any covered person to any doctor or type of doctor or institution, will not be covered under this Plan.

Additionally, if you or your eligible dependent are covered under an HMO or clinic which provides necessary treatment without charge, you or your eligible dependent must obtain the treatment from the HMO or clinic. No benefits will be payable under this Plan for the expense of any treatment which would have been provided by an HMO or clinic without charge.

Working Spouse Rule

Your working spouse must elect and maintain employer-sponsored health coverage if available. The Plan limits benefits for your spouse to 50% of covered expenses if your spouse does not elect and maintain employer-sponsored health coverage.

This means that if your spouse does not elect and maintain employer-sponsored health coverage, you could be responsible for a large portion of any expenses incurred.

Coordination of Benefits with Medicare

Benefits from this Plan are coordinated with Medicare. Medicare is a government program that provides health insurance and prescription drug coverage to individuals age 65 and older and to permanently disabled individuals.

Generally, if you work for an employer that has 20 or more employees, this Plan is primary and will pay benefits before Medicare in the following circumstances:

  • you or your eligible dependent are age 65 or older and covered by this Plan due to your current employment status;
  • you or your eligible dependent are under age 65 and entitled to Medicare due to Social Security disability and covered by this Plan due to your current employment status; or
  • you or your eligible dependent are entitled to Medicare because of End Stage Renal Disease during the coordination period described by the Medicare regulations (currently, the first 30 months).

At all other times, this Plan is secondary to Medicare when allowed by law.

Coordination of Benefits with Automobile and Similar Coverage

Benefits from this Plan will not be paid for the cost of care, treatment, services or supplies which are furnished by or are payable under any motor vehicle or automobile insurance policy or plan or any plan or policy covering loss, liability or damage caused by a third party, including but not limited to, “no fault” or uninsured or underinsured motorist coverage.

  

(Updated 06/23/16)