2011-2012 Full Benefits Summary - Office of Student Health Benefits

However, if the court decree requires one (1) of the parents to be responsible for the health careexpenses of the child, and the plan that covers that parent has actual knowledge of that requirement,that plan determines benefits first. This does not apply to any claim determination period or plan yearduring which any benefits are actually paid or provided before the plan has that actual knowledge.e. Active/inactive employee: The Plan that covers a person as an employee who is neither laid-off norretired (or as that employee’s dependent) determines benefits before a plan that covers that person as alaid-off or retired employee (or as that employee’s dependent). If the other plan does not have this rule,and if as a result the plans do not agree on the order of benefits, then this rule is ignored.f. Longer/shorter length of coverage: If none of the above determines the order of benefits, the plan that hascovered an employee, member, or subscriber longer determines benefits before the plan that hascovered that person for a shorter time.Effect on Benefits of This Student Health Benefit Plan1. When this section applies: When the Order of Benefits Rules above require This Student Health Benefit Planto be a Secondary Plan, this part applies. Benefits of This Student Health Benefit Plan may be reduced.2. Reduction in This Student Health Benefit Plan’s benefitsWhen the sum of:a. the benefits payable for allowable expenses under This Student Health Benefit Plan, without applyingcoordination of benefits; andb. the benefits payable for allowable expenses under the other plans, without applying coordination ofbenefits or a similar provision, whether or not claim is made, exceeds those allowable expenses in aclaim determination period. In that case, the benefits of This Student Health Benefit Plan are reduced sothat benefits payable under all plans do not exceed allowable expenses.When benefits of This Student Health Benefit Plan are reduced, each benefit is reduced in proportion andcharged against any applicable benefit limit of This Student Health Benefit Plan. Benefits saved by ThisStudent Health Benefit Plan due to coordination of benefits saving (credit reserve) are available for paymenton future claims during this Plan year. Credit reserve will start over for the next Plan year.Right to Receive and Release Needed InformationCertain facts are needed to apply these coordination of benefits rules. The Claims Administrator has the right todecide which facts are needed. The Claims Administrator may get needed facts from, or give them to, any otherorganization or person. They do not need to tell, or get the consent of, any person to do this. Each personclaiming benefits under This Student Health Benefit Plan must provide any facts needed to pay the claim.Facility of PaymentA payment made under another plan may include an amount that should have been paid under This StudentHealth Benefit Plan. If this happens, This Student Health Benefit Plan may pay that amount to the organizationthat made that payment. That amount will then be considered a benefit under This Student Health Benefit Plan.This Student Health Benefit Plan will not have to pay that amount again. The term “payment made” includesproviding benefits in the form of services, in which case “payment made” means reasonable cash value of thebenefits provided in the form of services.Right of RecoveryIf This Student Health Benefit Plan pays more than it should have paid under these coordination of benefit rules,This Student Health Benefit Plan may recover the excess from any of the following:1. the persons This Student Health Benefit Plan paid or for whom This Plan has paid;2. insurance companies; and3. other organizations.The amount paid includes the reasonable cash value of any benefits provided in the form of services.74