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SECTION 13.0 - COORDINATION OF BENEFITS

Most group health care programs, including your managed care program, contain a coordination of benefits provision. This provision is used when you, your spouse or your covered dependents are eligible for payment under more than one group health program. The object of coordination of benefits is to assure you that your covered expenses will be paid, while preventing duplicate benefit payments.


Here is how the coordination of benefits provision in your Blue Cross and Blue Shield coverage works:


When your other group coverage does not mention “coordination of benefits,” then that coverage pays first. Benefits paid or payable by the other group coverage will be taken into account in determining if additional benefit payments can be made under your program.


When the person who received care is covered as an employee under one group contract, and as a dependent under another, then the employee coverage pays first.


When a dependent child is covered under two group contracts, the contract covering the parent whose birthday falls earlier in the calendar year pays first. But, if both parents have the same birthday, the program which covered the parent longer will be the primary program. If the dependent child’s parents are separated or divorced, the following applies:

  1. If the parent with custody of the child has not remarried, the coverage of the parent with custody pays first.

  2. When a divorced parent with custody has remarried, the coverage of the parent with custody pays first but the stepparent's coverage pays before the coverage of the parent who does not have custody.

  3. Regardless of which parent has custody, whenever a court decree specifies the parent who is financially responsible for the child's health care expenses, the coverage of that parent pays first.


When none of the above circumstances applies, the coverage you have had for the longest time pays first; provided that:

  1. The benefits of a program covering the person as an employee other than a laid off or retired employee or as the dependent of such person shall be ,determined before the benefits of a program covering the person as a laid-off or retired participant or as a dependent of such person; and

  2. If the other program does not have a provision regarding laid-off or retired participants, and, as a result, the benefits of each program are determined after the other, then the provisions of (1) above shall not apply.


    If you receive more than you should have when your benefits are coordinated, you will be expected to repay any overpayment.


Coordination of benefits prevents duplication and works to the advantage of all members of the group. For more information regarding Coordination of Benefits, please refer to the material provided by the PPO Blue program.