Coverage under this Plan plus another Plan will not guarantee 100% reimbursement. 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.
Covered Dental Service, or reduce the benefits in proportion to the amount of the Copayment, Deductible, and/or Coinsurance amounts waived, forgiven or reduced, regardless of whether the provider represents that You remain responsible for any amounts that Your plan does not cover. We shall have the right to require You to provide proof sufficient to Us that You have made Your required cost share payment(s) prior to the payment of any benefits by Us. This exclusion includes, but is not limited to, charges of a Non-Participating Provider who has agreed to charge You or charged You at an In-Network benefits level or some other benefits level not otherwise applicable to the services received; • charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law; • Covered Dental Services to the extent that payment is unlawful where the Covered Person resides when the expenses are incurred; • charges for or in connection with experimental procedures or treatment methods not recognized and approved by the American Dental Association or the appropriate dental specialty organization; • charges which would not have been made in any facility, other than a hospital or a correctional institution owned or operated by the United States Government or by a state or municipal government if the person had no insurance; • services for which benefits are not payable according to the "General Limitations" section; • charges for care, treatment or surgery that is not Medically Necessary and/or Dentally Necessary; • athletic mouth guards. Should any law require coverage for any particular service(s) noted above, the exclusion or limitation for that service(s) shall not apply.
HCDFB-DEX110
06-21 V1
Coordination of Benefits This section applies if You or any one of Your Dependents are covered under more than one Plan and determines how benefits payable from all such Plans will be coordinated. You should file all claims with each Plan. Any other health coverage plans for You or any of Your covered Dependents are taken into account when benefits are paid.
myCigna.com
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