SSMC Employee Health Benefit Plan
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4. Claim Determination Period. The claim determination for coordination of benefits is done on an Incurred
expense basis and based on a Calendar Year period. However, it does not include any Allowable Fees
Incurred during any part of a Calendar Year during which a person has no coverage under This Plan, or any
part of the year before the date this COB provision takes effect.
5. Allowable Expense. The term `allowable expense' means health expenses, including deductibles and
copayments or coinsurance, that are cover ed at least in part by any of the plans covering the person. When
a Plan provides benefits in the form of medical services, (for example an HMO) the reasonable cash value
of the services will be considered an allowable expenses and a benefit paid. Any expenses or services that
are not covered by any of the plans will not be considered allowable COB expenses. The following are
examples of expenses not considered allowable expenses or otherwise limited under this COB provision:
a. If a covered Person is confined in a private Hospital room, the difference between the cost of a semi-
private room and the private room is not an allowable expense unless the primary plan routinely
includes coverage for Hospital private rooms.
b. If a person is covered by two or more plans that determine benefit payments based on Usual and
Customary (UCR) Charges, any amount more than the highest of the UCR charges for the specific
medical benefit is not an allowable expense.
c. If a person is covered by two or more plans that provide benefits or services based on negotiated fees,
any amount more than the highest of the negotiated fees for the specific medical benefit is not an
allowable expense.
d. If a person is covered by one plan that determines its benefits based on UCR charges and another
provides benefits or services based on negotiated fees, the primary plan's payment arrangements will
be the allowable expense for all plans.
e. The amount of benefits that are reduced by the primary plan because a Covered Person does not
comply with its plan provisions will be excluded under this COB provision. Examples of these
provisions include, but are not limited to, mandatory requirements of a benefit management program,
second surgical opinions, medical procedure review, pre-admission review or pre-certification of
Inpatient admissions, pre-approval requirements for certain treatment, and HMO or preferred Provider
arrangement.
f. As secondary payer, long term care, dental or vision or hearing aid expenses excluded under This Plan
will not be considered allowable expenses, even if such expenses were covered by the primary plan.
g. As secondary payer, This Plan will not consider any health benefits paid due to Mandatory No-fault
Automobile Coverage laws as allowable expense for COB. However, charges for health expenses
applied to the no-fault plan's deductibles, copayments or more than the cumulative benefit maximum
per accident will be considered as allowable expenses, if expenses otherwise covered by This Plan.
h. If Medicare is primary, charges more than the allowable expenses permitted under Medicare
regulations will not be considered allowable expenses for COB.
B. Order of Benefit Determination
If a Covered Person is eligible for Medicare, the order of benefit determination can be affected by Medicare Secondary
Payer (MSP) rules. Current MSP rules and any future changes in the MSP rules will automatically apply. Rule # 4
shown below applies if you or your Dependents are continuing this Plan coverage under COBRA or USERRA.
The order of benefit determination rules shown below designate which plan is the primary coverage and which
are secondary. The primary plan pays first without regard to the possibility that another plan could pay some
