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COORDINATION
OF BENEFITS
WITH
OTHER GROUP INSURANCE
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The
hospital, medical, dental and prescription benefits payable from this Plan will
be coordinated with those provided by any other group benefit or service plan.
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1. |
The
basic rule for the Operating Engineer is that this Fund is the primary carrier, that is, it pays benefits
first for the eligible Operating Engineer. |
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2. |
The
spouse's insurance coverage is the primary carrier for her benefits.
If the spouse is offered health insurance at no cost through his or her
employment, it is mandatory for the spouse to enroll in the employer's health
care plan.
If the spouse has HMO coverage, he/she cannot be covered by this Fund.
He/she must use the employer's HMO plan.
We will not coordinate benefits.
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3. |
In
the case of dependent children, the plan of the parent whose birthday falls
earlier in the year pays first, and the plan of the parent whose birthday falls
later in the year pays second. This
is known as the "birthday" rule.
This rule uses the month and day of birth, not year of birth, so age is
not a consideration. This rule does
not apply if the parents are divorced |
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4. |
In
the case of an Active employee who is married to either another Active employee
or a retired employee, benefits for allowable expenses shall be paid in an
amount twice that which would otherwise be allowed under this Plan but not to
exceed the amount of the billed charges. |
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NOTE:
AHF PROVIDERS DO NOT ACCEPT CONTRACTED RATES IF THIS FUND IS SECONDARY TO
ANOTHER GROUP INSURANCE.
IMPORTANT: NO MORE THAN 100% OF THE PRIMARY CARRIER'S ALLOWED AMOUNT WILL
BE PAID UNLESS THE PRIMARY CARRIER PAID THEIR ALLOWED AMOUNT IN FULL.
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CHILDREN
OF DIVORCED PARENTS
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| IMPORTANT:
In order for the Fund to continue coverage for a dependent
child after a divorce, the child must either live in the eligible member's
household or at school, OR a Qualified Medical Child Support Order* must require
the eligible member to furnish medical coverage for the child. |
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IF
THE CHILD DOES NOT QUALIFY AS AN ELIGIBLE DEPENDENT AS DESCRIBED ABOVE, THE
FOLLOWING COORDINATION OF BENEFITS RULES DO NOT APPLY.
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If
one of the parents was required by a Qualified Medical Child Support Order* to
provide health care coverage for the child:
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1. |
The
Plan of the parent who is responsible for health care coverage, as ordered by
the court, is primary. |
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2. |
The
Plan of the other parent is secondary. |
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If
the Qualified Medical Child Support Order* did not order either parent to provide
medical coverage:
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1. |
The Plan of the parent with custody
is primary. |
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2. |
The Plan of the step-parent (if
any) with custody is secondary. |
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3. |
The Plan of the parent without
custody is third UNLESS that parent is the operating engineer. Since
the child does not live with the operating engineer and the operating engineer
was not ordered to provide medical coverage, the child would not be an eligible
dependent |
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If
the parents were awarded joint custody by the court AND neither parent was
required by the Qualified Medical Child Support Order* to provide health care
coverage:
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1. |
The
Plan of the parent whose birthday falls earlier in the year is primary. |
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2. |
The
Plan of the parent whose birthday falls later is secondary. This rule uses the month and day of birth, not the year of birth.
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* In order to pay
benefits in accordance with a medical child support order, the Plan must
determine that the order is a Qualified Medical Child
Support Order (QMCSO). A medical child support order is a court order
that provides for medical child support or health benefit coverage with respect
to your dependent child. You may obtain a copy of the Plan’s procedures for
determining whether or not an order is qualified by contacting the
Administrative Office. There is no charge to obtain the procedures. |
