COORDINATION OF BENEFITS

(The coordination of benefits provision is referred to as “C.O.B.”)

Benefits are coordinated when both you and your spouse (and/or your dependent children) are covered by this Plan as well as by another group health plan (usually your spouse’s plan). Coordination allows benefits to be paid by two or more plans up to but not to exceed 100% of the allowable expenses on the claim.

General C.O.B. Rules

  1. Benefits are coordinated on all employee, retiree and dependent claims. C.O.B. applies only to medical, mental health, dental and vision care benefits—it doesn’t apply to Life Insurance, AD&D Insurance, Weekly Income Benefits, or the Lineco Member Assistance Program (MAP).
  2. The Fund Office may release or receive necessary information about your claim to or from other sources. You must furnish the Fund Office with any information they need to process your claim.
  3. You must file a claim for any benefits you are entitled to from any other source. Whether or not you file a claim with these other sources, your Plan payments will be calculated as though you have received any benefits you are entitled to from the other source(s).
  4. Benefits are coordinated with other group plans, including group Blue Cross and Blue Shield and blanket insurance plans, and with individual plans paid for by the individual if that plan has a C.O.B. provision. If you or your spouse are covered under another plan, you can contact the Fund Office to find out whether that plan fits the definition of a group plan.
  5. Benefits are also coordinated with Medicare. If a person is eligible for Medicare, the Plan will calculate benefits as though he is enrolled in both Part A AND Part B of Medicare, even if he has not actually enrolled in both Parts.
  6. When anyone in your family who is covered under another group health plan has a claim, be sure that you file claims with all plans and provide all required information about other coverage on all claim forms.
  7. If you and your spouse are both covered as employees under this Plan and one of you has a claim, the Plan will coordinate benefits on the claim (two claims must be submitted—one by you and one by your spouse).
  8. Benefits are paid under C.O.B. for allowable expenses, which are expenses that are eligible to be considered for reimbursement.

    When Lineco is the secondary plan, the following types of expenses will NOT be considered to be allowable expenses and no payment will be made for:
    • Any amount the primary plan didn’t cover because you did not follow its rules and procedures. For example, if the primary plan reduced its benefits because you did not obtain precertification, get a required second opinion, or use a PPO provider, etc., the reduced amount is not an allowable expense. This means that Lineco will not pay for the amount of any penalty reductions assessed by the primary plan because of your (or your family member's) failure to comply with the other plan's rules or procedures.
    • If there is a difference between the amount the primary plan allows and the amount allowable by Lineco, Lineco will coordinate its benefits using the higher amount. However, if the primary plan has a contract with the provider (HMOs and PPOs usually have such contracts with their providers), the combined payments of both plans will not be more than the primary plan's contract calls for. Exception: If both Lineco and the other plan have a contract with the same provider, the allowable expense will be the higher of the two contracted or negotiated fees.

Order of Benefit Payments

A plan that is required to pay its normal benefits on a claim before another plan pays its benefits is the primary plan, or pays first. The plan that makes payments based on the amount that is not paid by the primary plan is the secondary plan, or pays second. When a person who has a claim is covered under one or more other plans, this Plan will determine and pay its benefits in accordance with the first of the following rules that applies:

  1. If a person is covered under another group plan that doesn’t have C.O.B. rules, that other plan will pay its benefits first and this Plan will pay second.
  2. The plan covering the person for whom the claim is filed as an employee or retiree will pay first, and the plan covering the person as a dependent will pay second.
  3. The benefits of a plan which covers a person as an employee who is not retired will be paid before the benefits of a plan which covers that person as a retired employee. The same is true if a person is a dependent of a person who is covered under one plan as a retiree and the other plan as an employee.
  4. If a person who has COBRA coverage is also covered under another plan as an employee, retiree or dependent, the COBRA coverage is secondary.
  5. On claims for children, the following rules apply:
    1. The primary plan is the plan of the parent whose birthday is earlier in the year (called the birthday rule) if:
      • The parents are married; or
      • The parents are not separated (whether or not they ever have been married to each other); or
      • A court decree awards joint custody without specifying that one party has the responsibility to provide health coverage.
      If both parents have the same birthday, the plan that has covered either of the parents longer is primary.
    2. If the non-custodial parent is given responsibility for the child’s medical expenses in a divorce or separation decree, and if the non-custodial parent does provide health care coverage for the child, the plans will determine their benefits using the following order: (1) the plan of the non-custodial parent, (2) the plan of the custodial parent, (3) the plan of the spouse of custodial parent, and (4) the plan of the spouse of non-custodial parent.
    3. If the terms of a court decree state that one of the parents is responsible for the child’s health care expenses or health care coverage, then the responsible parent’s plan is primary. If the legally responsible parent does not have health coverage for the child, but his or her spouse does, the spouse’s plan becomes primary.
    4. If the parents are not married and not living together, or are separated or divorced and (1) no court decree allocates responsibility for the child’s health care expenses, or (2) if a court decree states that the custodial parent is responsible for the child’s health care expenses, the order of benefits for all possible plans is:
      • The plan of the custodial parent;
      • The plan of the spouse (if any) of the custodial parent;
      • The plan of the non-custodial parent; and then
      • The plan of the spouse (if any) of the non-custodial parent

If the above rules still don’t clearly show which plan should pay first, the plan that has covered the person (for whom the claim is filed) for the longest period of time will pay first. The plan which has covered the person for the next longest period of time will pay second, and so on.

C.O.B. With Sub-Plans - If Lineco is secondary on an covered person’s claim under its order of benefit determination rules, but the primary plan has a rule allowing it to pay less than its normal benefits when there is secondary coverage, then such individual will be deemed covered under Lineco’s sub-plan. The maximum payable by Lineco for all claims incurred by an individual covered under the sub-plan is $1,000 per calendar year, or, if less, the amount payable after application of Lineco’s coordination of benefits rules. If the sum of the primary plan’s sub-plan benefits, plus Lineco’s sub-plan benefits, plus any additional benefits payable by the primary plan’s regular benefit plan, is less than the amount otherwise payable under Lineco’s regular benefit plan, then Lineco’s regular benefit plan will pay the difference. If the primary plan pays the benefits it would have paid if the individual was not also covered under Lineco, then the individual will be deemed covered under Lineco’s regular benefit plan, and Lineco will coordinate its regular benefits as the secondary payer to the other plan.

C.O.B. With Medicare

Retirees (and Spouses) Eligible for Medicare - If you are an eligible retiree, and if you and/or your spouse are eligible for Medicare and have enrolled in both Medicare Part A AND Part B, this Plan will coordinate benefits with Medicare on your claims. This means that Medicare will pay first, and this Plan will pay after Medicare pays based on amounts not paid by Medicare.

IF YOU (OR YOUR SPOUSE) HAVE NOT ENROLLED IN BOTH MEDICARE PART A AND PART B, THIS PLAN WILL ASSUME THAT YOU HAVE ENROLLED AND WILL CALCULATE BENEFITS AS IF BENEFITS UNDER MEDICARE PART A AND B HAVE BEEN PAID. This means that this Plan will only pay benefits equal to the benefits it would have paid if you were enrolled in both Parts. You will have to pay the amount normally paid by Medicare. To avoid being confronted with large out-of-pocket expenses, be sure that both you and your spouse enroll in both Medicare Part A AND B when you are eligible to do so.

Medicare-Eligible Persons Under 65 (Employees and Their Dependents Only) - If any covered person is entitled to Medicare for reasons other than being 65 or older (for example, because of disability or being an End Stage Renal Disease beneficiary), this Plan will usually pay its benefits on that person’s claims before Medicare pays its benefits unless it is legally permitted to pay second. This provision doesn’t apply to retirees or their dependents.

Employees Continuing to Work After Age 65 (and Their Medicare-Eligible Spouses) - If you continue to work for a contributing employer who has 20 or more employees after you become age 65 and eligible for Medicare, you are entitled to the same benefits as employees under age 65 as long as you meet the regular eligibility rules. This Plan will be your primary provider of health care benefits unless it is legally permitted to pay second. Medicare will pay secondary benefits only for expenses covered by it and which are not paid by the Plan.

If your dependent spouse is age 65 or older and eligible for Medicare while you are still working and eligible (regardless of your age), this Plan will usually pay its normal benefits for her before Medicare pays unless it is legally permitted to pay second. If she is covered under her own plan, her plan will pay first, this Plan will usually pay second, and Medicare will pay last.

You (and/or your spouse) can decline coverage under this Plan. If you do, Medicare will be your only health care coverage. You will not get any secondary benefits from this Plan. If you and/or your spouse prefer Medicare as your only health care coverage when you are age 65, contact the Fund Office (or your spouse should notify her own plan). Unless you make such a choice, this Plan will usually continue to pay primary benefits for you (and its normal benefits for your spouse) as long as you stay regularly eligible unless it is legally permitted to pay second.

If you continue to work for a contributing employer who has fewer than 20 total employees after you are age 65, this Plan will usually pay benefits for you and your spouse after Medicare pays its benefits unless this Plan is legally required to pay first.

Enrollment in Medicare - You can apply for Medicare during the period that begins three months before and ends three months after your 65th birthday. Both you and your spouse are each responsible for enrolling in Medicare Part A and Part B when eligible to do so. At present there is no cost to you for Part A, which provides benefits for hospital and certain other expenses. Part B covers such items as doctors' services. The government makes a monthly charge for Part B. If you or your spouse want information about Medicare enrollment or benefits, contact your local Social Security office.

Excess Coverage Limitation

Regardless of any other rule stating otherwise, all benefits payable under this Plan will be limited to being in excess of the benefits which are payable by any other group plan, group insurance policy or blanket insurance policy which is or purports to be an excess policy or an excess plan paying benefits only in excess of benefits provided by any other plan or policy.

If an entity or insurer of such other group excess plan, group excess policy or blanket insurance policy agrees to pay benefits as if it were not an excess plan or policy, this Plan’s benefits will be payable without regard to the provisions of the previous paragraph, subject to the C.O.B. provisions stated in this section.

No benefits are payable by this Plan for any injury or sickness for which there is other non-group coverage through an automobile insurance policy or plan providing medical, sickness, or similar payments or medical expense coverage, regardless of whether the other coverage is primary, excess or contingent to this Plan.