Important Notice: This provision applies to all health expense benefits under this plan except prescription drug expense insurance. It does not apply to death, dismemberment, or loss of income benefits.
Purpose of This Provision: An employee may be covered for health expense benefits by more than one plan. For instance, he may be covered by this plan as an employee and by another plan as a dependent of his spouse. If he is, this provision allows us to coordinate what we pay with what another plan pays. We do this so the covered person doesn't collect more in benefits than he incurs in charges.
Definitions:
"We" and "our" mean The Guardian Life Insurance Company of America.
"Plan" means any of the following that provides health expense benefits or services: (a) group or blanket insurance plans; (b) group Blue Cross plans, group Blue Shield plans, or other service or prepayment plans on a group basis; (c) union welfare plans, employer plans, employee benefits plans, trusteed labor and management plans, or other plans for members of a group; and (d) programs or coverages required or provided by law.
"Plan" does not include Medicaid or any other government program or coverage which we are not allowed to coordinate with by law. Nor does it include any plan we say we supplement. Plans that we supplement are named in the schedule.
"This plan" means the part of our group plan subject to this provision.
"Member" means the person who receives a certificate or other proof of coverage from a plan that covers him for health expense benefits.
"Dependent" means a person who is covered by a plan for health expense benefits, but not as a member.
"Allowable expense" means any necessary, reasonable, and usual expense for health care incurred by a member or dependent under both this plan and at least one other plan. When a plan provides service instead of cash payment, we view the reasonable cash value of each service as an allowable expense and as a benefit paid. We also view benefits payable by another plan as an allowable expense and as a benefit paid, whether or not a claim is filed under that plan.
"Claim determination period" means a calendar year in which a member or dependent is covered by this plan and at least one other plan and incurs one or more allowable expense under such plans.
How This Provision Works: We apply this provision when a member or dependent is covered by more than one plan. When this happens we consider each plan separately when coordinating payments.
In order to apply this provision, one of the plans is called the primary plan. All other plans are called secondary plans. The primary plan pays first, ignoring all other plans. The secondary plans then pay the remaining unpaid allowable expenses, but no plan pays more than it would have without this provision.
If a plan has no coordination provision, it is primary. But, during any claim determination period, when this plan and at least one other plan have coordination provisions, the rules that govern which plan pays first are as follows:
If rules (A), (B), (C) and (D) don't determine which plan pays first. the plan that has covered the person for the longer time pays first.
If, when we apply this provision, we pay less than we would otherwise pay, we apply only that reduced amount against payment limits of this plan.
Our Rights to Certain Information: In order to coordinate benefits, we need certain information. An employee must supply us with as much of that information as he can. But if he can't give us all the information we need, we have the right to get this information from any source. And if another insurer needs information to apply its coordination provision, we have the right to give that insurer such information. If we give or got information under this section we can't be held liable for such action.
When payments that should have been made by this plan have been made by another plan, we have the right to repay that plan. If we do so, we're no longer liable for that amount. And if we pay out more than we should have, we have the right to recover the excess payment.
Small Claims Waiver: We don't coordinate payments on claims of less than $50,00. But if, during any claim determination period, more allowable expenses are incurred that raise the claim above $50.00 we'll count the entire amount of the claim when we coordinate.
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(C) Except for dependent children of separated or divorced parents, the following governs which plan pays first when the person is a dependent of a member.
A plan that covers a person as a dependent of a male pays before a plan that covers that person as a dependent of a female.
All the other terms of the Coordination of Benefits provision remain the same
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HOW THIS PLAN INTERACTS WITH MEDICARE
The following provisions explain how this plan's group health benefits interact with the benefits available under Medicare. A covered person may be eligible for Medicare by reason of age, disability, or End Stage Renal Disease. Different rules apply to each type of Medicare eligibility, as shown below.
With respect to the following provisions:
(1) A covered person is considered to be eligible for Medicare by reason of age from the first day of the month during which he reaches age 65. However, if the covered person is born on the first day of a month, he is considered to be eligible for Medicare from the first day of the month which is immediately prior to his 65th birthday.
(2) "Group health benefits" means any dental, hospital, major medical, prescription drug and surgical coverages provided by this plan.
(3) A "primary" health plan pays benefits for a covered person's covered charge first, ignoring what the covered person's "secondary" plan pays. A "secondary" health plan then pays the remaining unpaid allowable expenses. See this plan's "Coordination of Benefits" provision for a definition of "allowable expense".
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MEDICARE ELIGIBILITY BY REASON OF AGE
Applicability
This section applies to an employee or his insured spouse who is eligible for Medicare by reason of age.
Under this section, such an employee or insured spouse is referred to as a "Medicare eligible."
This section does not apply to: (a) a covered person othe'r than an employee or insured spouse; (b) an employee or insured spouse who is under age 65; or (c) a covered person who is eligible for Medicare solely on the basis of End Stage Renal Disease.
When An Employee or Insured Spouse Becomes Eligible for Medicare
When an employee or insured spouse becomes eligible for Medicare by
reason of age, he must choose one of the two options below.
Option (A) - The Medicare eligible may choose this plan as his primary health
plan. If he does, Medicare will be his secondary health plan. See "When This Plan Is Primary" below, for details.
Option (B) - The Medicare eligible may choose Medicare as his primary health plan. If he does, group health benefits under this plan will end. See "When Medicare Is Primary" below, for details.
If the Medicare eligible fails to choose either option when he becomes eligible for Medicare by reason of age, we will pay benefits as if he had chosen Option (A).
When This Plan Is Primary
When a Medicare eligible chooses this plan as his primary health plan, if he
incurs a covered charge for which benefits are payable under both this plan and Medicare, this plan is considered primary. This plan pays first, ignoring Medicare. Medicare is considered the secondary plan.
When Medicare Is Primary
If a Medicare eligible chooses Medicare as his primary health plan, he will no
longer be covered for such benefits by this plan. Coverage under this plan will end on the date the Medicare eligible elects Medicare as his primary health plan.
A Medicare eligible who elects Medicare as his primary health plan, may later change such election, and choose this plan as his primary health plan. However, the Medicare eligible must submit proof that he's insurable, and he will not be covered by this plan until we approve the 1)roof in writing.
CGP-3-R-MED-89-2 8560.0012
MEDICARE ELIGIBILITY BY REASON OF DISABILITY
Applicability
This section applies to a covered person who is: (a) under age 65; and lb) eligible for Medicare by reason of disability.
Under this section, such covered person is referred to as a "disabled Medicare eligible."
This section does not apply to: (a) a covered person who is eligible for Medicare by reason of age; or (b) a covered person who is eligible for Medicare solely on the basis of End Stage Renal Disease.
When A Covered Person Becomes Eligible for Medicare
When a covered person becomes eligible for Medicare by reason of
disability, this plan supplements the benefits provided by Medicare.
If a disabled Medicare eligible incurs a covered charge for Which benefits are
payable under both this plan and Medicare, we subtract what Medicare pays from what we'd normally pay.
If a covered person is eligible for Medicare by reason of disability, he must be covered by both Parts A and B. If he's not, he must meet the Medicare Alternate Deductible.
For any covered person who is eligible for Medicare by reason of disability, but is not insured by both Parts A and B, the Medicare Alternate Deductible is equal to the Cash Deductible plus what Parts A and B of Medicare would have paid had the covered person been so insured.
After the 18 month period as described in "Medicare Eligibility By Reason Of End Stage Renal Disease," with respect to a covered person who is eligible for Medicare solely on the basis of End Stage Renal Disease, but is not insured by both Parts A and B, the Medicare Alternate Deductible is equal to the Cash Deductible plus what Parts A and B of Medicare would have paid had the covered person been so insured.
GP-3-R-MED-89-7 6560.0019
MEDICARE ELIGIBILITY BY REASON OF END STAGE RENAL DISEASE
Applicability
This section applies to a covered person who is eligible for Medicare solely on the basis of End Stage Renal Disease (ESRD).
Under this section, such a covered person is referred to as an "ESRD Medicare eligible."
This section does not apply to a covered person who is eligible for Medicare by reason of age or disability.
When A Covered Person Becomes Eligible for Medicare due to ESRD
When a covered person becomes eligible for Medicare solely on the basis of
ESRD, for a period of up to 18 consecutive months, if he incurs a charge for
the treatment of ESRD for which benefits are payable under both this plan
and Medicare, this plan is considered primary. This plan pays first, ignoring
Medicare. Medicare is considered the secondary plan.
This 18 month period begins on the earlier of: (a) the first day of the month during which a regular course of renal dialysis starts; and (b) with respect to a ESRD Medicare eligible who receives a kidney transplant, the first day of the month during which such covered person becomes eligible for Medicare.
After the 18 month period described above ends, if an ESRD Medicare eligible incurs a charge for which benefits are payable under both this plan and Medicare, we supplement what Medicare pays. We subtract what Medicare pays from what we'd normally pay. If a covered person is eligible for Medicare solely on the basis of ESRD, he must be covered by both Parts A and B. If he's not, he must meet the Medicare Alternate Deductible
The Medicare Alternate Deductible is equal to the Cash Deductible plus what Parts A and B of Medicare would have paid had the covered person been so insured.
CGP-3-R-MED-89-8
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