AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

COORDINATION OF BENEFITS
The Plan’s coordination of benefits (“COB”) procedures will apply when you or your covered Dependents
are covered under both the Plan and another health care plan, such as one provided by your spouse’s
employer, Medicare or a no-fault insurance policy.
COORDINATING WITH ANOTHER EMPLOYER’S PLAN
COB is how plans coordinate benefits when you are covered by more than one health care or motor
vehicle insurance plan or policy. The Plan, which is administered by the Plan Administrator and the
Claims Administrator, requires that your benefit payments be coordinated with benefit payments from
another health care or motor vehicle insurance plan or policy for services and/or supplies that may be
payable under either plan, so that payment responsibilities will be fair. If you are covered by more than
one health care or motor vehicle insurance plan or policy, COB guidelines (explained below) determine
which plan pays for Covered Services first. COB letters of inquiry, which request information about other
plans, may be sent on an annual or more frequent basis in order to keep the Plan’s records up to date.
The plan that pays first is your primary plan. This plan must provide you with the maximum benefits
available to you under that plan. The plan that pays second is your secondary plan. This plan provides
payments toward the balance of the cost of Covered Services — up to the total allowed amount under
that plan.
COB makes sure that the level of payment, when added to the benefits payable under another plan, will
cover up to the total of the eligible expenses. COB also makes sure that the combined payments of all
coverage will not exceed the actual cost approved for your care.
GUIDELINES TO DETERMINE WHICH PLAN IS PRIMARY AND SECONDARY
When both this Plan, paying as secondary, and the primary plan have a preferred Provider arrangement
in place, payment will be made up to the preferred Provider allowance available to the primary plan.
NOTE: For information regarding coordination with Medicare, please refer to the section of this SPD titled
Coordination With Medicare.
If the claimant is an active Associate this Plan will be primary to:
• A plan covering the claimant as a Dependent;
• A plan covering the claimant as a COBRA participant;
• A plan covering the claimant as a retiree in another group health plan; or
• A plan covering the claimant as a Dependent of a retiree in another group plan.
If the claimant is the spouse of an active Associate this Plan will be primary to a plan covering the spouse
as a COBRA participant.
This Plan will be secondary to:
• A plan covering the spouse as a retiree, or
• A plan covering the spouse as an active Associate.
If the claimant is the child of an active Associate this Plan will be primary to a plan covering the child as a:
• Dependent of the Associate’s spouse, provided the spouse is also an active employee, if the
Associate’s birthday (day and month) is earlier in the year than the Associate’s spouse’s birthday
• COBRA participant or a Dependent of a COBRA participant;
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