Kaiser Permanente HMO

SECTION 6 - COORDINATION OF BENEFITS

Kaiser Permanente coordinates benefits with any other group medical coverage you may have.

Coordination of Benefits (COB) is a provision in group plan contracts that enables a carrier to coordinate its benefit payments for members who are covered by another benefit carrier so that no more than 100% of the cost of the medical services is paid by both carriers.

COB divides the responsibility for payments between a primary and secondary carrier so that the primary carrier pays its full benefit for covered services, and the secondary carrier pays the outstanding balance of covered charges up to the full cost of the services. Generally the carrier selected at your place of employment is your primary carrier. However, if one carrier has a COB provision and the other does not, the one that does not is always the primary carrier.

A plan is any carrier which provides coverage for the individual for whom claim is made. A plan does not include individual policies other than individual no-fault automobile insurance, by whatever name called.

2.: Other arrangements, whether insured or uninsured, covering individuals in a group. COB will not apply to plans which provide Coverage for accidents for students, including athletic injuries;

3.: Plans designed to pay a fixed-dollar benefit per day while the covered individual is Hospital confined, but which at the time of claim, allow the individual to elect an alternate benefit;

5.: Plans of other Hospital or medical service organizations on a group basis;

8.: Coverage under federal government plans or programs, including Medicare;

9.: Coverage required or provided by law. COB will not apply to any state programs which provide benefits for individuals unable to pay for their care;

Note: This Plan is always a secondary plan to benefits provided under any mandatory no-fault auto insurance act in the state in which the covered individual resides.

The benefits of this Plan will not be available to you to the extent of minimum benefits required by the "no-fault" law for injuries suffered by you while operating or riding in a motor vehicle owned by you if said vehicle is in operation on public highways and such vehicle is not covered by no-fault automobile insurance as required by law. This denial of benefits does not apply to any other person injured in a motor vehicle accident if the injured person is a non-owner operator, passenger or a pedestrian and such other person is not covered by no-fault automobile insurance.

1.: Any plan which does not have a COB or similar provision will pay its benefits first.

2.: All plans which have a COB or a similar provision will pay benefits in the order determined by the following rules:

a.: A plan which covers the individual as an Employee/member will be considered before a plan which covers the individual as a Dependent.

b.: For Dependent children, the plan which pays first is determined by the parents' birthdays. The plan which covers the parent whose month and date of birth occurs earliest in the Calendar Year will be considered first. If both parents have the same birthday, the plan covering the parent for the longest continuous period of time will be considered first.

Except that, when the natural parents of a Dependent child are divorced or legally separated and the child is covered by two or more plans, the following rules apply:

a.: The plan of the Parent with custody of the child will be considered first;

b.: Then, the plan of the spouse of the parent with custody of the child; and

d.: 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 plan obligated to pay or provide the benefits of that parent has actual knowledge of those terms, that plan is primary. This paragraph does not apply with respect to any plan year during which any benefits are actually paid or provided before the payer has that actual knowledge. If the Participant's child is participating in the Plan pursuant to a Qualified Medical Child Support Order, then that legal order determines which parent is responsible for the child's medical care coverage.

3.: A plan which covers the individual as an active Employee/member, or as the Dependent of an active Employee/ member, will be considered before a plan which covers the individual as a laid-off or retired Employee/member.

4.: If the above rules do not establish an order of benefit determination (such as when two plans cover the individual as an Employee/member), the plan which has covered the individual for the longest continuous period of time will be considered first.

1.: Upon request, the covered individual is required to furnish Kaiser Permanente with complete information concerning all plans which cover the individual for whom the claim is being made.

2.: As permitted by law, Kaiser Permanente may, without the Covered Person's consent:

b.: Release to such other plans any information it has with respect to any individual's COB claim.

3.: If payments which should have been made by this Plan have been made under any other plans, this Plan may reimburse such other plans to the extent necessary to make this provision work. Any such payment will be a benefit paid under this Plan.

4.: If Kaiser Permanente has processed payment for benefits which result in payment in excess of the amount necessary under this Plan to make this provision work, Kaiser Permanente has the right to recover such excess payment from:

January 2004

Questions about this site: webmaster@fanda.ucar.edu