SSMC Employee Health Benefit Plan
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SECTION VII - COORDINATION OF BENEFITS (COB)
Information necessary to administer the COB provision will be required when claims are submitted. If you or
your Dependents are covered by more than one plan, all claims should be filed with each plan. You should file
claims first with the primary plan, then to the secondary plan(s) with copies of the primary plan explanation of
benefits or denial.
Special rules apply when you or your Dependents are covered by more than one group health plan. This can
happen if you, your Spouse, and/or children are covered under This Plan and another plan (with your Spouse's
employer, for example). Coordination of Benefits (COB) means that the benefits payable under this Plan, as
shown in the preceding pages, are coordinated with the benefits payable under another group plan. The purpose
of COB is to avoid duplicate payments that could exceed 100% of the total allowable expenses.
One of the two or more plans involved is the primary plan and the other plan(s) is the secondary plan(s). The
order of benefit determination shown later in this section determines which plan will pay as the primary plan.
The primary plan pays first without regard to the possibility that another plan may cover some expenses. The
secondary plan pays after the primary plan and may reduce its benefits so that payments from all involved plans
do not exceed 100% of Allowable Fees.
A. COB Terms and Definitions
The following definitions show the meaning of terms used in the administration of this COB provision.
1. This Plan. Whenever the term "This Plan" is used in this section, it means this SSMC Employee Health
Benefits Plan.
2. Plan. The term `plan' used in this section includes any of the following:
a. A group insurance or group type coverage, whether insured or uninsured, including, but not limited to,
coverage such as prepayment; indemnity; Hospital or medical service organizations; group practice or
individual practice; health maintenance organizations or similar type organizations; group auto plan or
individual auto health coverage on an automobile leased or owned by an employer; student coverage
sponsored by, or provided through, a school or other educational facility except school accident type
coverage.
b. Coverage under a governmental plan, or coverage required or provided by federal, state, or local laws,
including mandatory No-fault Automobile Coverage. This does not include government coverage,
such as Medicaid that by its terms, prohibits coordination for the allowable expenses. This Plan
integrates its benefits with Medicare. See Section VI - Medicare Integration with Plan Benefits.
Each contract, polic y or other arrangement for coverage under " a " or " b" is a separate plan. Also, if an
arrangement has two parts and COB rules apply only to one, each part is a separate plan.
3. Primary Plan/Secondary Plan. The order of benefit rules determines whether This Plan is a primary or
secondary plan to another plan covering the same person. When This Plan is primary, its benefits are
determined before those of other plans without regard to the other plan benefits. When This Plan is the
secondary plan, its benefits are determined after the primary plan and may be reduced because of the
primary plan benefits. If a person is covered by more than one secondary plan, the order of benefit rules
determine the order in which secondary plans are based in relation to each other. Each secondary plan will
take into consideration the benefits of the primary plan or plans and the benefits of any other plan that,
under the order of benefit rules, has its benefits determined before those of that secondary plan.
