COORDINATION OF BENEFITS
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The Plan includes a coordination of benefits provision. This provision applies to the following benefits: Major Medical, Hospital, Dental, Prescription Drugs, Wellness, Mental Health and Chemical Dependency.
Each time you submit a claim, you have an obligation to advise the Fund of the existence of any other group insurance or health plan covering you, your spouse or any of your dependents covered by the Plan.
How Coordination Works
Coordination of benefits operates so that one of the plans (called the primary plan) will pay its benefits first as if the other plan (called the secondary plan) did not exist. The secondary plan may then pay additional benefits. If a primary plan is “closed panel” (that means that you can only get benefits from participating providers) and you obtain benefits from a nonparticipating provider, the secondary plan is treated as a primary plan (except for emergency services or authorized referrals paid or provided by the primary plan).
The general rule works like this: If you or your dependents are also covered under another group health plan or covered as both a participant and dependent under the Plan, the amount received from all plans will never be more than 100% of the allowable expenses. (See special rule that applies to individuals eligible for, but not covered under, the SAG Producers Health Plan.)
Allowable expenses means necessary and reasonable expenses for health care services, supplies or treatment (including deductibles, coinsurance or copayments) that are covered, in whole or in part, by this Plan or another plan. However, it will not be an allowable expense to the extent that a primary plan reduced your benefits because you did not comply with that plan's claims procedure, pre-certification, or second surgical procedure requirements. For example, allowable expenses do not include such things as the difference in cost between a private room and a semiprivate room in a hospital (unless the stay in a private room is medically necessary or one of the plans routinely covers it) or amounts in excess of usual and customary fees (if at least two plans compute their benefits on that basis). Where one plan calculates benefits based on usual and customary fees and the other calculates benefits based on negotiated fees, the primary plan's arrangement is the allowable expense.
Benefits under the Plan will be coordinated with any group plan, whether insured or uninsured, providing coverage for hospital, medical, wellness, dental, or prescription benefits. This includes:
Claims will be paid on an individual claim-by-claim basis, rather than a cumulative basis over the course of a calendar year. This means that, when you are covered by two separate plans and the Health Plan is a secondary payor, the Health Plan will, for each separate claim, pay the lesser of the amount it would have paid if it were primary or the amount of your out-of-pocket expenses for that particular claim (but not taking into account your out-of-pocket expenses for other claims in the calendar year). The total reimbursement during a calendar year from both carriers may in some cases amount to less than 100% of your charges. When the Plan is secondary, it never pays more for benefits than it would have paid for each claim, as it is submitted, had it been the plan that paid primary.
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The Plan includes a coordination of benefits provision. This provision applies to the following benefits: Major Medical, Hospital, Dental, Prescription Drugs, Wellness, Mental Health and Chemical Dependency.
Each time you submit a claim, you have an obligation to advise the Fund of the existence of any other group insurance or health plan covering you, your spouse or any of your dependents covered by the Plan.
How Coordination Works
Coordination of benefits operates so that one of the plans (called the primary plan) will pay its benefits first as if the other plan (called the secondary plan) did not exist. The secondary plan may then pay additional benefits. If a primary plan is “closed panel” (that means that you can only get benefits from participating providers) and you obtain benefits from a nonparticipating provider, the secondary plan is treated as a primary plan (except for emergency services or authorized referrals paid or provided by the primary plan).
The general rule works like this: If you or your dependents are also covered under another group health plan or covered as both a participant and dependent under the Plan, the amount received from all plans will never be more than 100% of the allowable expenses. (See special rule that applies to individuals eligible for, but not covered under, the SAG Producers Health Plan.)
Allowable expenses means necessary and reasonable expenses for health care services, supplies or treatment (including deductibles, coinsurance or copayments) that are covered, in whole or in part, by this Plan or another plan. However, it will not be an allowable expense to the extent that a primary plan reduced your benefits because you did not comply with that plan's claims procedure, pre-certification, or second surgical procedure requirements. For example, allowable expenses do not include such things as the difference in cost between a private room and a semiprivate room in a hospital (unless the stay in a private room is medically necessary or one of the plans routinely covers it) or amounts in excess of usual and customary fees (if at least two plans compute their benefits on that basis). Where one plan calculates benefits based on usual and customary fees and the other calculates benefits based on negotiated fees, the primary plan's arrangement is the allowable expense.
Benefits under the Plan will be coordinated with any group plan, whether insured or uninsured, providing coverage for hospital, medical, wellness, dental, or prescription benefits. This includes:
- group blanket or franchise insurance;
- group subscriber contracts and group‑type contracts;
- uninsured group or group‑type coverage arrangements;
- group Blue Cross and Blue Shield plans;
- group practice and any other group prepayment coverage;
- group and group‑type coverage in “closed panel” plans;
- labor‑management trusteed plans;
- union welfare plans;
- employer organization plans;
- medicaI care portions of group long‑term care contracts;
- automobile "no fault" and "fault" contracts;
- Medicare or any governmental benefits (as permitted by law) other than a state Medicaid plan.
- school accident‑type coverage;
- Medicare supplemental policies;
- group or group‑type hospital indemnity benefits of $200 per day or less;
- non‑group insurance or subscriber contracts;
- non‑group coverage through “closed panel” plans;
- non‑group coverage under other prepayment, group practice and individual practice plans.
Claims will be paid on an individual claim-by-claim basis, rather than a cumulative basis over the course of a calendar year. This means that, when you are covered by two separate plans and the Health Plan is a secondary payor, the Health Plan will, for each separate claim, pay the lesser of the amount it would have paid if it were primary or the amount of your out-of-pocket expenses for that particular claim (but not taking into account your out-of-pocket expenses for other claims in the calendar year). The total reimbursement during a calendar year from both carriers may in some cases amount to less than 100% of your charges. When the Plan is secondary, it never pays more for benefits than it would have paid for each claim, as it is submitted, had it been the plan that paid primary.
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