D. COORDINATION OF BENEFITS

Members of a family are often covered by more than one group health insurance plan. As a result, two or more plans are paying for the same claim. To help control costs, the Plan provides for the coordination of benefits.

1. How Does Coordination Work?

If you or your Dependents are also covered under another group plan, the total amount received from all plans will never be more than 100% of the Covered Expenses as defined in Section XIV, Definitions. Benefits are reduced only to the extent necessary to prevent any person from making a profit.

This Coordination of Benefits provision shall not apply to any private coverage which you or your Dependents purchase individually.

2. Which Plan Pays First?

If both plans have Coordination of Benefits provisions, such as this one, the plan that insures you as a member pays first. If you are insured as a member under two plans, the plan which has insured you longer is the primary. However, if you are insured as an Active member under one plan and a laid-off employee or as a retiree under another plan, the plan that insures you as an Active member will pay its benefits first; this does not apply if either plan does not have a provision regarding laid-off or retired members. If one plan does not have a Coordination of Benefits provision, that plan is always primary. If a Dependent child is covered under two plans, the plan of the parent whose birthday occurs earliest in the year will pay benefits first. However, if the parents are divorced or are separated, the plan of the parent with custody pays benefits first. In the event of qualified joint custody, the plan of the parent whose birthday occurs earliest in the year will be the primary. If the parent with custody remarries, the order of payment is as follows:

1. Natural parent with whom child resides;
2. Stepparent with whom child resides; then
3. Natural parent not having custody of the child.

This order of payment can change if the divorce decree child support order directs one of the parents to be financially responsible for the medical, dental or other health care expenses of the child.

3. Coordination with Medicare.

Coverage under this Plan will be secondary if you are eligible for Medicare and you are a retired member or a Dependent of a retired member.

Coverage under this Plan will be primary if you are eligible for Medicare and you are:

1. an Active Participant and over age 65; or
2. over age 65, a Dependent and your spouse is an Active member.

In each case, where this Plan continues as the primary carrier, the Plan will pay first and Medicare will pay second. However, you and your spouse have the option of electing Medicare as primary. Please note: If Medicare is elected as primary, coverage under this Plan will cease as required by Federal Law.

4. Medicare Benefits Due to Total Disability.

The following rules apply with respect to the coordination of benefits with Medicare if you or your Dependent becomes entitled to Medicare benefits prior to age 65 due to total disability or end stage renal disease. Upon attainment of age 65, the rules for coordination of benefits with Medicare at age 65 apply.

This Plan will be a primary Plan to Medicare during any waiting period for Medicare benefits due to total disability or end stage renal disease. After the Medicare waiting period has been met, and you or your Dependent is entitled to Medicare benefits, this Plan will be secondary, with one exception: except that the Plan will be primary to Medicare if you are an Active member, and you or your Dependent is entitled to Medicare benefits due to total disability for other than end stage renal disease; however, the Plan will be secondary to Medicare if you are an Active member, and you or your Dependent is entitled to Medicare benefits due to end stage renal disease.

5. Right to Obtain or Release Information.

The Plan may obtain or release any information necessary to implement these provisions. You must declare your coverage under other group plans. The Plan can pay to another paying organization amounts warranted to satisfy the intent of this provision and, to the extent of such payment, be discharged from liability for that claim. The Plan can also recover amounts that are overpaid under this provision from you from an insurance company, or from another organization. Information necessary to the administration of this provision will be required of you at the time a claim is submitted. Payment of the claim may be delayed if the required information is not provided.