The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
Appealing a Prior Authorization Decision
If you disagree with BCBS’ prior authorization determination, you can seek additional review of
that claim by following the procedure described under “Request for Review of Adverse Benefit
Determinations” in the “Internal ERISA Claims Procedures” section in this SPD.
When You Have Other Coverage – BCBS of MN
If you or your dependents are covered by the Early Retiree Medical or Comprehensive option
and by another employer’s health plan, the U.S. Bank option will integrate its payments for
medical related services with those of the other group plan. For information related to pharmacy,
see the “When You Have Other Coverage – Medco” section in this SPD. The U.S. Bank options
do not integrate payments with non-group health plans or individual polices issued in most
states.*
* Pursuant to law, some states are required to integrate with non-group or individual health plans. In these instances,
normal rules (as explained above) are followed for determining which plan is primary.
Integration means that benefits from both plans are coordinated. You and your dependents will
not, in most cases, receive 100% reimbursement for health care expenses when you have
coverage in two group plans. If certain benefit plans are structured identically, the secondary
plan might not pay any benefits. As a result, it may not be economically advantageous to be
covered by two group plans.
In order for integration to occur, one of the plans is determined to be primary and the other,
secondary. The primary plan pays first and the secondary plan pays second.
The following rules apply to determine which plan is primary:
• Plans providing benefits or services under workers’ compensation, personal injury protection
(PIP) or no-fault insurance are always considered primary.
• Dependents of pre-65 non-Medicare eligible retirees eligible for Medicare solely on the basis
of having end-stage renal disease (first 30 months only), the benefit option is primary.
• A plan that covers a person as an employee or a dependent of an employee is primary over a
plan that covers a person under COBRA or other continuation coverage required by statute.
• A retiree’s health plan is considered primary for the retiree unless the retiree is also covered
by an active employee plan. A plan that covers the retiree as a dependent (unless it is an
active employee plan) is secondary.
• If a retiree or dependent is covered by an active employee plan, the active plan is considered
primary for that individual.
• For dependent children covered by the plans of both parents, the “birthday rule” applies,
which means the plan of the parent whose birthday falls earlier in the year pays first.
• Dependents of pre-65 non-Medicare eligible retirees eligible for Medicare due to disability
and who are not working, Medicare Parts A and B are primary.
• For children of legally separated or divorced parents, the plan of the parent who has child
custody pays first (unless the divorce decree indicates otherwise).
• If you remarry or enter into a domestic partnership and you have custody, your plan is
primary - followed by your new spouse’s/domestic partner’s plan and then your former
spouse’s/domestic partner’s plan.
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