Common use of Order of Benefit Determination Rules Clause in Contracts

Order of Benefit Determination Rules. This Plan determines its order of benefits using the first of the following rules which applies: (a) The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, Medicare is secondary to the Plan covering the person as a dependent and primary to the Plan covering the person as other than a dependent, then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering that person as other than a dependent. Except in the case of legal separation or divorce (further described below), when This Plan and another Plan cover the same child as a dependent of different persons, called “parents”: (1) the benefits of the Plan of the parent whose birthday falls earlier in a year are determined before those of the Plan of the parent whose birthday falls later in that year; but (2) if both parents have the same birthday, the benefits of the Plan which covered the parent longer are determined before those of the Plan which covered the other parent for a shorter period of time. However, if the other Plan does not have the rule described immediately above, and if, as a result, the Plans do not agree on the Order of Benefits, the rule in the other Plan will determine the order of benefits. (b) If two or more Plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order: (1) first, the Plan of the parent with custody of the child; (2) then, the Plan of the spouse of the parent with custody of the child; and (3) finally, the Plan of the parent not having custody of the child. However, 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 entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply with respect to any Claim Determination Period or Plan Year during which any benefits are actually paid or provided before the entity has that actual knowledge. (c) The benefits of a Plan which covers a person as an employee who is neither laid off, retired or continuing coverage under a right of continuation (or as a dependent of the person) are determined before those of a Plan which covers that person as a laid off, retired or continuing coverage (or as a dependent of that person). If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the Order of Benefits, this rule is ignored. (d) If none of the above rules determines the Order of Benefits, the benefits of the Plan which covered an employee, member, or subscriber longer are determined before those of the Plan which covered that person for the shorter time.

Order of Benefit Determination Rules. 1. When there is a basis for a Claim under This Plan and another plan, This Plan is a Secondary Plan which has its Benefits determined after those of the other plan, unless: a. the other plan has rules coordinating its benefits with those of This Plan; and, b. both those rules and This Plan's rules, in subparagraph b. below, require that This Plan's Benefits be determined before those of the other plan. 2. This Plan determines its order of benefits Benefits using the first of the following rules which applies: (a) a. Non-dependent/Dependent: The benefits Benefits of the Plan plan which covers the person as an employee, member or subscriber a Plan Participant (that is, other than as a dependentDependent) are determined before those of the Plan plan which covers the person as a dependentDependent; except that if the person is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is secondary is: (1) Secondary to the Plan plan covering the person as a dependent and primary Dependent, and (2) Primary to the Plan plan covering the person as other than a dependentDependent (e.g., a retired employee), then the benefits Benefits of the Plan plan covering the person as a dependent Dependent are determined before those of the Plan plan covering that person as other than a dependent. Dependent. b. Dependent Child/Parents Not Separated or Divorced: Except as stated in the case of legal separation or divorce subparagraph b. (further described 3) below), when This Plan and another Plan plan cover the same child as a dependent Dependent of different persons, called “"parents”": (1) the benefits Benefits of the Plan plan of the parent whose birthday falls earlier in a the calendar year are determined before those of the Plan plan of the parent whose birthday falls later in that the calendar year; but (2) if both parents have the same birthday, the benefits Benefits of the Plan plan which covered the one parent longer are determined before those of the Plan plan which covered the other parent for a shorter period of time. However, if the other Plan plan does not have the rule described in (a) immediately above, but instead has a rule based upon the gender of the parent, and if, as a result, the Plans plans do not agree on the Order order of Benefits, the rule in the other Plan plan will determine the order of benefitsBenefits. (b) If two or more Plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order: (1) first, the Plan of the parent with custody of the child; (2) then, the Plan of the spouse of the parent with custody of the child; and (3) finally, the Plan of the parent not having custody of the child. However, 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 entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply with respect to any Claim Determination Period or Plan Year during which any benefits are actually paid or provided before the entity has that actual knowledge. (c) The benefits of a Plan which covers a person as an employee who is neither laid off, retired or continuing coverage under a right of continuation (or as a dependent of the person) are determined before those of a Plan which covers that person as a laid off, retired or continuing coverage (or as a dependent of that person). If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the Order of Benefits, this rule is ignored. (d) If none of the above rules determines the Order of Benefits, the benefits of the Plan which covered an employee, member, or subscriber longer are determined before those of the Plan which covered that person for the shorter time.

Order of Benefit Determination Rules. 1. When there is a basis for a claim under This Plan and another Plan, This Plan is a Secondary Plan whose Benefits are determined after those of other Plans, unless: a. The other Plan has rules coordinating its benefits with those of This Plan; and b. Both those rules and This Plan’s rules, in Section IX.C(2) below, require that This Plan’s Benefits be determined before those of the other Plan. 2. This Plan determines its order of benefits Benefits using the first of the following rules which that applies: (a) a. The benefits of the Plan which that covers the a person as an employee, member employee or subscriber (that is, as other than as a dependent) are determined before those the benefits of the Plan which that covers the person as a dependent; except that . However, this rule does not apply if the person is also a Medicare beneficiarybeneficiary and, as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: (i) Secondary to the Plan covering him or her as a dependent; and (ii) Primary to the Plan covering him or her as other than a dependent (for example, a retired employee), then the order of benefits determination is secondary to reversed so that the Plan covering the person as a dependent an employee, subscriber or retiree is secondary and primary to the other Plan covering the person is primary. b. Except as other than a dependent, then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering that person as other than a dependent. Except stated in the case of legal separation or divorce (further described Section IX.C(2)(c) below), when This Plan and another Plan cover the same child as a dependent Child of different persons, called “parents”parents who are not separated or divorced: (1i) the The benefits of the Plan of the parent whose birthday falls earlier in a the year are determined before those of the Plan of the parent whose birthday falls later in that the year; but (2ii) if If both parents have the same birthday, the benefits of the Plan which that covered the parent parents longer are determined before those of the Plan which that covered the other parent them for a shorter period of time. However, if the other Plan does not have the rule described immediately above, and if, as a result, the Plans do not agree on the Order of Benefits, the rule in the other Plan will determine the order of benefits. (b) c. If two or more Plans cover a person as than one Plan covers a dependent child Child of separated or divorced or separated parents, benefits for the child Child are determined in this order: (1i) firstFirst, the Plan of the parent with custody of the childChild; (2ii) thenThen, the Plan of the spouse of the parent with custody of the child; andChild; (3iii) finallyThen, the Plan of the parent not having without custody of the child. HoweverChild; and (iv) Then, 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 entity obligated to pay or provide the benefits of the Plan of that the spouse of the parent has actual knowledge without custody of those terms, the benefits of that Plan are determined first. This paragraph does not apply with respect to any Claim Determination Period or Plan Year during which any benefits are actually paid or provided before the entity has that actual knowledgeChild. (c) d. The benefits of a Plan which that covers a person as an employee who is neither laid off, off nor retired or continuing coverage under a right of continuation (or as a dependent of the personthat employee’s dependent) are determined before those of a Plan which that covers that person as a laid off, laid-off or retired or continuing coverage employee (or as that e. If a dependent person whose coverage is provided under a right of continuation pursuant to federal law (that is, COBRA) or state law also is covered under another Plan, the benefits of the Plan covering the person as an employee or a subscriber (or as that person)’s dependent) will be determined before the benefits under the continuation coverage. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the Order order of Benefitsbenefits, this rule is Section IX.C(2)(e) will be ignored. (d) f. If none of the above rules determines the Order order of Benefitsbenefits, the benefits of the Plan which that covered an employee, member, employee or a subscriber longer are determined before those the benefits of the Plan which that covered that person him or her for the shorter timeterm.

Order of Benefit Determination Rules. This Plan determines its order of benefits using the first of the following rules which applies: (a) The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, Medicare is secondary to the Plan covering the person as a dependent and primary to the Plan covering the person as other than a dependent, then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering that person as other than a dependent. Except in the case of legal separation or divorce (further described below), when This Plan and another Plan cover the same child as a dependent of different persons, called “"parents”": (1) the benefits of the Plan of the parent whose birthday falls earlier in a year are determined before those of the Plan of the parent whose birthday falls later in that year; but (2) if both parents have the same birthday, the benefits of the Plan which covered the parent longer are determined before those of the Plan which covered the other parent for a shorter period of time. However, if the other Plan does not have the rule described immediately above, and if, as a result, the Plans do not agree on the Order of Benefits, the rule in the other Plan will determine the order of benefits. (b) If two or more Plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order: : (1) first, the Plan of the parent with custody of the child; ; (2) then, the Plan of the spouse of the parent with custody of the child; and and (3) finally, the Plan of the parent not having custody of the child. However, 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 entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply with respect to any Claim Determination Period or Plan Year during which any benefits are actually paid or provided before the entity has that actual knowledge. (c) The benefits of a Plan which covers a person as an employee who is neither laid off, retired or continuing coverage under a right of continuation (or as a dependent of the person) are determined before those of a Plan which covers that person as a laid off, retired or continuing coverage (or as a dependent of that person). If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the Order of Benefits, this rule is ignored. (d) If none of the above rules determines the Order of Benefits, the benefits of the Plan which covered an employee, member, or subscriber longer are determined before those of the Plan which covered that person for the shorter time.

Order of Benefit Determination Rules. This A Plan determines its order that does not have a coordination of benefits using rule consistent with this section shall always be the Primary Plan. If the Plan does have a coordination of benefits rule consistent with this section, the first of the following rules which appliesthat applies to the situation is the one to use: (a) 1. The benefits of Plan that covers you as a Subscriber or an employee shall be the Primary Plan and the Plan that covers you as a Dependent shall be the Secondary Plan; 2. If you are a Dependent child whose parents are not divorced or legally separated, the Primary Plan shall be the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the person as a dependent; except that if the person is also a Medicare beneficiary, Medicare is secondary to the Plan covering the person as a dependent and primary to the Plan covering the person as other than a dependent, then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering that person as other than a dependent. Except in the case of legal separation or divorce (further described below), when This Plan and another Plan cover the same child as a dependent of different persons, called “parents”: (1) the benefits of the Plan of the parent whose birthday falls earlier first in a the calendar year are determined before those of the Plan of the parent whose birthday falls later in that year; but (2) if both parents have the same birthday, the benefits of the Plan which covered the parent longer are determined before those of the Plan which covered the other parent for a shorter period of time. However, if the other Plan does not have the rule described immediately above, and if, as a result, Subscriber or employee; 3. If you are the Plans do not agree on the Order of Benefits, the rule in the other Plan will determine the order of benefits. (b) If two or more Plans cover a person as a dependent child Dependent of divorced or separated parents, benefits for the child are Dependent shall be determined in this the following order: (1) a. first, if a court decree states that one parent is responsible for the child's health care expenses or health coverage and the Plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge; b. then, the Plan of the parent with custody of the child; (2) c. then, the Plan of the spouse of the parent with custody of the child; and; (3) finallyd. then, the Plan of the parent not having custody of the child. However, if and e. finally, the specific terms of a court decree state that one Plan of the parents is responsible for spouse of the health care expenses parent not having custody of the child, and the entity obligated to pay or provide the benefits of the . SAMPLE DOCUMENT 4. The Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply with respect to any Claim Determination Period or Plan Year during which any benefits are actually paid or provided before the entity has that actual knowledge. (c) The benefits of a Plan which covers a person you as an active employee who is neither laid off, retired or continuing coverage under a right of continuation (or as a dependent of that employee's Dependent) shall be the person) are determined before those of a Primary Plan which and the Plan that covers that person you as a laid off, laid-off or retired or continuing coverage employee (or as a dependent of that person)employee's Dependent) shall be the Secondary Plan. If the other Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this ruleparagraph shall not apply. 5. The Plan that covers you under a right of continuation which is provided by federal or state law shall be the Secondary Plan and the Plan that covers you as an active employee or retiree (or as that employee's Dependent) shall be the Primary Plan. If the other Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply. 6. If one of the Plans that covers you is issued out of the state whose laws govern this Agreement and determines the order of benefits based upon the gender of a parent, and if, as a result, the Plans do not agree on the Order order of Benefitsbenefit determination, this rule is ignored. (d) the Plan with the gender rules shall determine the order of benefits. If none of the above rules determines the Order order of Benefitsbenefits, the benefits of the Plan which that has covered an employee, member, or subscriber longer are determined before those of the Plan which covered that person you for the shorter timelonger period of time shall be primary. When coordinating benefits with Medicare, this Plan will be the Secondary Plan and determine benefits after Medicare, where permitted by the Social Security Act of 1965, as amended. However, when more than one Plan is secondary to Medicare, the benefit determination rules identified above, will be used to determine how benefits will be coordinated.