Community First Health Plans - EOC: Coordination Rules

If a Member is eligible to receive benefits under other health care plan(s). Community First will coordinate our benefits with those of any other plan(s) that provides benefits to You.

Part V of this Certificate, EFFECT OF MEDICARE ON THE GROUP HEALTH CARE COVERAGE, contains important additional information about coordinating Group Health Care Coverage with Medicare.

DEFINITIONS
1. Health Care Program: Any of the following which provide benefits or services for, or by reason of, medical, dental, vision care or treatment:
  1. Coverage under a governmental plan or required or provided by law. This does not include a state plan under Medicaid or any law or plan when, by law, its benefits are excess to those of any private insurance program or other nongovernmental program.
  2. Group insurance or other coverage for persons in a group, whether insured or uninsured. This includes prepayment, group practice or individual practice coverage. But this does not include school accident-type coverage for grammar school, hih school, and college students.
2. Separate Program: Each contract or other arrangement for coverage listed above is a Separate Program. If an arrangement has two parts and COB rules apply to one of the two, each of the parts is a separate program.
3. Primary or Secondary Plan. The rules establishing the order of benefit determination whether this plan is Primary or Secondary.
  1. Primary Plan benefits are determined before those of the other plan.
  2. If a health care plan does not contain a Coordination of Benefits provision, that health care plan is primary. The primary health care plan pays benefits before the secondary health care plan pays. If Community First is determined to be the secondary payor, then Community First will be liable only for the amount due under the seconday plan rules, regardless of whether or not a payment is made by the primary plan.
4. Allowable Expense: The usual and prevailing charge or
  negotiated rate, whichever is less, for a needed service or supply, when the charge, service or supply is covered at least in part by one or more Programs of the same type (dental, vision care, or medical program) covering the person for whom claim is made.
  
  When a Program provides benefits in the form of services, the Reasonable Cash Value for each service rendered will be considered both an Allowable Expense and a benefit paid. When payment under a Program is based on a contracted fee, that fee or the physician’s usual charge, whichever is less, will be considered the Allowable Expense.
  
  If a Member has expenses for a stay in a Hospital private room, the term Allowable Expense does not include the difference between the charge for the Hospital private room and the eligible charge for a Hospital room under this Program, unless:
  1. the Hospital private room charges are a covered expense under one of the Programs; or
  2. the person’s stay in a Hospital private room is Medically Necessary in terms of generally accepted medical practice.
  The term Allowable Expense does not include any amount that is not payable by Community First because a Member does not adhere to the Managed Care Provisions (as defined below) of Community First.
5. Managed Care Provisions: Those provisions of a contract that are intended to reduce unnecessary medical care or to make medical services and supplies available at a reduced cost. Examples of Managed Care Provisions include, but are not limited to, second surgical opinion programs, Pre-authorization programs, and preferred provider arrangements.
6. Claim Determination Period: A Contract Year, but, for a person, this does not include any part of the Contract Year while the person has no coverage under this Program or any part of the Contract Year before the date these or similar rules take effect.
EFFECT ON BENEFITS
1. This Program’s Rules for the Order in which Benefits are Determined: When a Member’s health care is the basis for a claim, this Program determines its order of benefits using the first of the following rules that applies:
  1. Non-Dependent/Dependent: The benefits of a Program that covers the person other than as a dependent are determined before those of a Program that covers the person as a dependent. But if the person is also covered under Medicare and, if by its rules, Medicare is:
    (1) secondary to the Program covering the person as a dependent; and
    
    (2) primary to the Program covering the Member as other than a dependent (e.g. a retired employee), then the benefits of the Program covering the person as a
    dependent are determined before those of the
    Program covering that Member as other than a
    dependent.
  2. Dependent Child/Parents Not Separated or Divorced: Except as stated below when this Program and another Program cover the same child as a dependent of different persons, called “parents”:
    
    (1) the benefits of the Program of the parent whose
    birthday falls earlier in a year are determined before
    those of the Program of the parent whose birthday
    falls later in that year; but
    
    (2)if both parents have the same birthday, the benefits of the Program which covered the parent longer are
    determined before those of the Program which
    covered the other parent for a shorter period of time.
    
    However, if the other Program does not have the rule
    immediately above, but instead has a rule based on gender of the parent, and if as a result the Programs do not agree on the order of benefits, the rule on the other Program will determine the order of benefits.
  3. Dependent Child/Separated or Divorced Parents: If two or more Programs cover a Member who is a dependent child of divorced or separated parents, benefits for the child are determined in this order:
    
    (1) first, the Program of the parent with custody of the
    child;
    
    (2) then, the Program of the spouse of the parent with custody of the child; and
    
    (3) finally, the Program of the parent not having custody of the child.
    
    However, the following exceptions apply:
    (1) If the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the Program of that parent has actual knowledge of those terms, the benefits of that Program are determined first. This paragraph does not apply when any benefits are actually paid or provided before the entity has that actual knowledge.
    (2) If the specific terms of a court decree state that the parents shall share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, benefits for the child are determined in accordance with subparagraph B.1.b. above ("Dependent Child/Parents Not Separated or Divorced").
  4. Active/Inactive Eligible Employee: The benefits of a Program which covers a person as an employee who is neither laid off nor retired, or as that employee's dependent, are determined before those of a Program which covers that person as a laid off or retired employee or as that employee's dependent. If the other Program does not have this rule, and if, as a result, the Programs do not agree on the order of benefits, this rule (d) is ignored.
  5. Continuation Coverage: If a Member whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another Program, benefits are determined in this order:
    (1) first, the benefits of the Program covering the person as an employee, or as that person's dependent;
    (2) second, the benefits under the continuation coverage.
    
    (3) If the other Program does not have the rule described above, and if as a result, the Programs do not agree on the order of benefits, this rule is ignored.
  6. Longer/Shorter Length of Coverage: If none of the above rules determine the order of benefits, the benefits of the Program which covered a Member longer are determined before those of the Program which covered that Member for the shorter term.
2. Effect of Reduction in Benefits: When these rules reduce this Program's benefits, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of this Program.
RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION
Certain facts are needed to apply these coordination of benefits rules. Community First has the right to decide which facts it needs. It may get needed facts for, or give them to, any other organization or person as allowable by law. Community First need not tell, or get the consent of, any person to do this. Each person claiming benefits under this Program must give Community First any facts it needs to pay the claim.
FACILITY OF PAYMENT
A payment made under another Program may include an amount for a benefit which should have been provided under this Program. If it does, Community First may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit provided under this Program. Community First will have no further liability with respect to that amount. The term "payment made" includes providing benefits in the form of services, in which case the payment made shall be deemed to be the actual costs of any benefits provided in the form of services.
RIGHT OF RECOVERY
If payments have been made by Community First that are more than what should have ben paid under the COB provisions, Community First shall have the right to recover only the excess amount that we paid from one or more of the persons or organizations that may be responsible for the services and benefits provided.