Definitions For the purposes of this section, the following terms have the meanings set forth below: A. Plan. A Plan is any of the following that provides benefits or services for medical or dental care or treatment. Plan includes group and non-group insurance contracts, health maintenance organization (HMO) contracts, Closed Panel Plans or other forms of group or non-group type coverage (whether insured or uninsured); and medical or dental benefits under group or individual automobile contracts; Medicare, Medicaid or any other federal governmental plan, as permitted by law. Each Plan or part of a Plan which has the right to coordinate benefits will be considered a separate Plan. B. Closed Panel Plan. A Plan that provides medical or dental benefits primarily in the form of services through a panel of employed or contracted providers, and that limits or excludes benefits provided by providers outside of the panel, except in the case of emergency or if referred by a provider within the panel. C. Primary Plan. The Plan that determines and provides or pays benefits without taking into consideration the existence of any other Plan. A Plan that does not contain a coordination of benefits provision that is consistent with this section is always primary. D. Secondary Plan. A Plan that determines, and may reduce its benefits after taking into consideration, the benefits provided or paid by the Primary Plan. A Secondary Plan may also recover from the Primary Plan the Reasonable Cash Value of any services it provided to You. E. Allowable Expenses. The amount of charges considered for payment under the Plan for a Covered Dental Service prior to any reductions due to Coinsurance or Deductible amounts. If We contract with an entity to arrange for the provision of Covered Dental Services through that entity’s contracted network of health care providers, the amount that We have agreed to pay that entity is the allowable amount used to determine Your Coinsurance or Deductible payments. If the Plan provides benefits in the form of services, the Reasonable Cash Value of each service is the Allowable Expense and is a paid benefit. Examples of expenses or services that are not Allowable Expenses include, but are not limited to the following: • An expense or service or a portion of an expense or service that is not covered by any of the Plans is not an Allowable Expense. • If You are covered by two or more Plans that provide services or supplies on the basis of Reasonable and
Customary fees, any amount in excess of the highest Reasonable and Customary fee is not an Allowable Expense. • If You are covered by one Plan that provides services or supplies on the basis of Reasonable and Customary fees and one Plan that provides services and supplies on the basis of negotiated fees, the Primary Plan's fee arrangement shall be the Allowable Expense. • If Your benefits are reduced under the Primary Plan (through the imposition of a higher Coinsurance percentage, a Deductible, and/or a penalty) because You did not comply with Plan provisions or because You did not use a Participating Provider, the amount of the reduction is not an Allowable Expense. Such Plan provisions include second surgical opinions and precertification of services. F. Custodial Parent . The parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one-half of the Calendar Year, excluding any temporary visitation. Order of Benefit Determination Rules A Plan that does not have a coordination of benefits rule consistent with this section shall always be the Primary Plan. If the Plan does have a coordination of benefits rule consistent with this section, the first of the following rules that applies to the situation is the one to use: • Employee: The Plan that covers a person as an Employee shall be the Primary Plan and the Plan that covers a person as a Dependent shall be the Secondary Plan. • Dependent: For a Dependent child whose parents are not divorced or legally separated, the Primary Plan shall be the Plan which covers the parent whose birthday falls first in the Calendar Year. • For the Dependent of divorced or separated parents, benefits for the Dependent shall be determined in the following order: • first, if a court decree states that one parent is responsible for the child's healthcare expenses or health coverage and the Plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge; • then, the Plan of the parent with custody of the child; • then, the Plan of the Spouse of the parent with custody of the child; • then, the Plan of the noncustodial parent of the child; and • finally, the Plan of the Spouse of the parent not having custody of the child.
myCigna.com
19
Made with FlippingBook flipbook maker