Secondary Plan Benefits Sample Clauses

Secondary Plan Benefits. This provision applies when this Contract is a Secondary Plan. If this Contract is a Secondary Plan, CHL will calculate the amount of benefits that it would normally pay in the absence of the Primary Plan and apply that payable amount to any allowable expense that is unpaid by the Primary Plan. Deductibles, Coinsurance and Copayments under this Contract will be used in the calculation of the benefits. CHL will credit to the Deductible under this Contract any amounts that would have been credited to the Deductible in the absence of other Coverage. Nothing contained in this COB provision is intended to require a Secondary Plan to make payment for all or part of any service that is not covered under the plan. In the event that CHL, as secondary, authorizes services from a Non-Participating Provider, and if the Primary Plan denies the services, CHL will base its payment on the Allowable Amount. The Member will be responsible to pay the difference between the Allowable Amount, as specified by CHL, and the Provider’s actual billed charges, in addition to any Copayment, Coinsurance, and/or Deductible. If a Member is covered by a Primary Plan that calculates benefits on the basis of usual and customary fees, and this Contract provides benefits or services on the basis of negotiated fees, the Primary Plan’s payment arrangement shall be the allowable expense for all plans. However, if the Provider has contracted with CHL to provide the service for a specific negotiated fee or payment that is different than the Primary Plan’s payment arrangement and if the Provider’s contract permits, that negotiated fee or payment shall be the allowable expense used by CHL to determine its benefits. If this Contract is the Secondary Plan according to the Order of Benefit Determination and the other plan claims to be “always secondary” or uses order of benefit determination rules inconsistent with those above, this Plan shall pay its benefits first, but the amount paid shall be calculated as if this Plan is a secondary plan. The other plan or the Member needs to provide CHL with the information necessary for CHL to determine secondary benefits within a reasonable time. CHL shall assume its benefits are identical to the Primary Plan’s and pay secondary plan benefits accordingly, subject to adjustment upon receipt of the information requested from the Member. If this Plan is a Secondary Plan according to the Order of Benefit Determination, prior authorization is required for all servic...
Sample 1
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Related to Secondary Plan Benefits

  • Program Benefits Under the Probation Status, the Participating Contractor will be eligible for all contractor incentives, its customers will have access to financing offered through the Program, and income- eligible households will be eligible to receive Program incentives.

  • Sponsorship Benefits 3.1 INREV agrees to grant the Sponsor the above chosen and described sponsorship benefits.

  • Health Benefits The method for determining the Employer bi-weekly contributions to the cost of employee health insurance programs under the Federal Employees Health Benefits Program (FEHBP) will be as follows:

  • Covered Benefits and Services The Contractor shall provide to its Hoosier Healthwise members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered by the IHCP, and included in the Indiana Administrative Code and under the Contract with the State. A covered service is considered medically necessary if it meets the definition as set forth in 405 IAC 5-2-17. The Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with CFR 438.210(a)(4), which specifies when Contractors may place appropriate limits on services:  On the basis of criteria applied under the State plan, such as medical necessity; or  For the purpose of utilization control, provided the services furnished are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.

  • Education Benefits Notwithstanding the provisions of Article 5, academic staff members who qualify for benefits in accordance with Article 23.5.2.1 may take a credit, or non-credit language class offered by the University provided it does not interfere with performance of duties as determined by the Xxxx. The member and the Xxxx may discuss ways in which duties may be reassigned to make it possible for the member to take the class. Upon successful completion, reimbursement of tuition will be provided for one class per semester.

  • Retiree Health Benefits 1. There is currently in effect a retiree health benefit program for retired members of LACERS under LAAC Division 4, Chapter 11. All covered employees who are members of LACERS, regardless of retirement tier, shall contribute to LACERS four percent (4%) of their pre-tax compensation earnable toward vested retiree health benefits as provided by this program. The retiree health benefit available under this program is a vested benefit for all covered employees who make this contribution, including employees enrolled in LACERS Tier 3.

  • Superior Benefits Employees receiving benefits and/or wages specified in this Agreement, superior to those provided in this Agreement, shall remain at the superior benefit level which was in effect on the effective date of this Agreement, until such time as such superior benefits are surpassed by the benefits and/or wages provided in succeeding agreements. This provision applies only to employees on staff as of the effective date of this Agreement.

  • Basic Plan All services are subject to an annual deductible of $50 per person and $100 per family. Preventive services are covered at 100%. After paying the deductible, the plan provides usual, customary, and reasonable (UCR) coverage at 100% for diagnostic and restorative services, and 80% for major services. Orthodontia is not covered.

  • STAFF BENEFITS 7.1.1 The present staff benefits consisting of the University of Manitoba Pension Plan (1993), Group Term Life Insurance Plan, Group Term Dependent Insurance Plan, Accidental Death and Dismemberment (Basic), Accidental Death and Dismemberment (Voluntary), University of Manitoba Long-Term Disability Income Plan, Group Health Insurance Policy 20778 GH (including the Health Care Spending Account), Group Dental Plan Policy 67000, and the University Employee Assistance Program shall continue to cover eligible Members for the duration of this Agreement.

  • Retirement Benefits Due to either investment or employment during the marriage, either the Husband or Wife: (check one) ☐ - DO NOT have retirement plans. ☐ - HAVE retirement plans. The Couple has the following retirement plans: (“Retirement Plans”). Upon signing this Agreement, the Retirement Plans shall be owned by: (check one) ☐ - Husband ☐ - Wife ☐ - Both Spouses ☐ - Other. .

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