2012-038 Human Resources - Delta Dental Claims & Administrative fees

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2. Those rules and this Plan's rules require that this Plan's benefits be deternuned first. Delta Dental deternunes which plan is the Primary Plan by using the first of the following rules that applies: The benefits of the plan that covers you as an employee or a Subscriber (that is, as other than a dependent) are determined before those of the plan that covers you as a dependent. This rule does not apply if you are 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: a. Secondary to the plan covering you as a dependent; and b. Primary to the plan covering you as other than a dependent (for example, as a retired employee). 2. Delta Dental uses the birthday rule when more than one plan covers a dependent child of parents who aze not divorced or separated. Under this rule: a. The benefits of the plan of the parent whose birthday falls eazlier in the year are deternuned before the benefits of the plan of the parent whose birthday falls later in that year, but b. If both parents have the same birthday, the benefits of the plan that covered the parents longer are deternuned before the benefits of the plan that covered them for a shorter period of time. If the other plan does not use the birthday rule, but instead uses a rule based upon the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the other plan's rule deternunes the order of benefits. 3. When more than one plan covers a dependent child of divorced or separated parents, the child's benefits are detennined in this order: a. First, the plan of the parent with custody of the Child; b. Then, the plan of the spouse of the parent with custody of the Child; c. Then, the plan of the parent without custody of the Child; and d. Then, the plan of the spouse of the parent without custody of the Child. 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. However, if tYie specific terms of a court decree state that one of the parents is responsible for the child's health care expenses, and the entity obligated to pay or provide the benefits of that parent's plan has actual knowledge of those terms, that plan's benefits aze deternuned first. The other parent's plan is the Secondary Plan. This paragraph does not apply with respect to any benefit year during which any benefits are actually paid or provided before the entity has that actual knowledge. If the specific terms of the court decree state that the parents will share custody without stating that one of the parents is responsible for the child's health care expenses, the plans covering the Child are subject to the birthday rule. 4. The benefits of a plan that covers you as an employee who is neither laid off nor retired (or as your dependent) are deternuned before those of a plan that covers you as a laid-off or retired employee (or as your dependent). ff 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. 5. . If your coverage is provided under a right of continuation pursuant to federal law (COBR.A) or state law and you are also covered under another plan, the benefits of the plan covering you as an employee or a Subscriber (or as your dependent) will be deternuned before the benefits under the continuation coverage. ff 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. 6. If none of the above rules deternunes the order of benefits, the benefits of the plan that covered you longer are detemuned before those of the Plan that covered you for the shorter term. How Delta Dental Pays as Primary Plan When Delta Dental is the Primary Plan, it will pay for Covered Services as if you had no other coverage. Form No. 1752-NC ,~ 3 NCPPOpIus-A Ot/2012