Common use of Coordination of Benefits Clause in Contracts

Coordination of Benefits. In the event a member is covered under another plan or policy which provides coverage, benefits or services (plan) that are covered benefits under this dental plan, then the benefits of this plan shall be coordinated with the other plan according to regulations on “Coordination of Benefits”. Covered California’s standard benefit design requires that stand alone dental plans offering the pediatric dental essential health benefit, such as this CDN plan, whether as a separate benefit or combined with a family dental benefit, cover benefits as a secondary dental benefit plan payer. This means that the primary dental benefit payer is a health plan purchased through Covered California which includes pediatric dental essential health benefits. Your primary dental benefit plan will pay the maximum amount required by its plan contract with you when your primary dental benefit plan is coordinating its benefits with CDN. This means that CDN will pay the lesser of either the amount that it would have paid in the absence of any other dental benefit coverage when a primary dental benefits plan is coordinating benefits with your CDN plan, or your total out-of- pocket cost payable under the primary dental benefit plan for benefits covered under your CDN plan. These regulations determine which plan is primary and which is secondary under various circumstances. Generally, they result in a group plan being primary over an individual plan and that a plan covering the member as a subscriber is primary over a plan covering the member as a dependent. Typically, Coordination of Benefits will result in the following: If the other coverage is a group indemnity plan: • If the group indemnity coverage is primary, the provider will usually bill the carrier for their Usual and Customary Fees, and the member will be charged the copayment under the secondary plan less the amount received from the primary coverage. • If the group indemnity coverage is secondary, the provider will bill the carrier for the amount of copayments under the primary plan, and the member will be responsible for the copayments under the primary plan less the amount paid by the secondary carrier. If the other coverage is a prepaid plan: • If the provider participates in both plans, the member should be charged the lower copayment(s) of the two plans. • If the provider does not participate in both plans, the plan that the provider participates in will be primary, and the other plan will typically deny coverage because the member received services from a non-participating provider. Members may not receive benefits for more than their out of pocket costs for the services provided as a result of Coordination of Benefits. A copy of the Coordination of Benefits regulations may be obtained from CDN. The Plan and/or its treating providers reserve the right to recover the cost or value, as set forth in Section 3040 of the Civil Code, of covered services provided to a Member that resulted from or were caused by third parties who are subsequently determined to be responsible for the injury to the Member.

Appears in 25 contracts

Samples: Group Subscriber Agreement, Group Subscriber Agreement, Group Subscriber Agreement

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Coordination of Benefits. In the event a member is covered under another plan or policy which provides coverage, benefits or services (plan) that are covered benefits under this dental plan, then the benefits of this plan shall be coordinated with the other plan according to regulations on “Coordination of Benefits”. Covered California’s standard benefit design requires that stand alone dental plans offering the pediatric dental essential health benefit, such as this CDN plan, whether as a separate benefit or combined with a family dental benefit, cover benefits as a secondary dental benefit plan payer. This means that the primary dental benefit payer is a health plan purchased through Covered California which includes pediatric dental essential health benefits. Your primary dental benefit plan will pay the maximum amount required by its plan contract with you when your primary dental benefit plan is coordinating its benefits with CDN. This means that CDN will pay the lesser of either the amount that it would have paid in the absence of any other dental benefit coverage when a primary dental benefits plan is coordinating benefits with your CDN plan, or your total out-of- pocket cost payable under the primary dental benefit plan for benefits covered under your CDN plan. These regulations determine which plan is primary and which is secondary under various circumstances. Generally, they result in a group plan being primary over an individual plan and that a plan covering the member as a subscriber is primary over a plan covering the member as a dependent. Typically, Coordination of Benefits will result in the following: If the other coverage is a group indemnity plan: • If the group indemnity coverage is primary, the provider will usually bill the carrier for their Usual and Customary Fees, and the member will be charged the copayment under the secondary plan less the amount received from the primary coverage. • If the group indemnity coverage is secondary, the provider will bill the carrier for the amount of copayments under the primary plan, and the member will be responsible for the copayments under the primary plan less the amount paid by the secondary carrier. If the other coverage is a prepaid plan: • If the provider participates in both plans, the member should be charged the lower copayment(s) of the two plans. • If the provider does not participate in both plans, the plan that the provider participates in will be primary, and the other plan will typically deny coverage because the member received services from a non-participating provider. Members may not receive benefits for more than their out of pocket costs for the services provided as a result of Coordination of Benefits. A copy of the Coordination of Benefits regulations may be obtained from CDN. This individual plan is secondary to all other group coverage the member may have. The Plan and/or its treating providers reserve the right to recover the cost or value, as set forth in Section 3040 of the Civil Code, of covered services provided to a Member that resulted from or were caused by third parties who are subsequently determined to be responsible for the injury to the Member.

Appears in 7 contracts

Samples: Individual Subscriber Agreement, Individual Subscriber Agreement, Individual Subscriber Agreement

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