SSMC Employee Health Benefit Plan
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expenses. A secondary plan pays after the primary plan and reduces its available benefits so that payments
from all involved plans do not exceed 100% of the total allowable expenses.
This Plan is always secondary payer to any health plans that pay without regard to coverage by other plans.
This Plan is always secondary to government plans or coverage provided by federal, local, or state laws unless
otherwise prohibited by that law. For example: This Plan is secondary to New York State mandatory No-fault
Automobile Coverage. However, this Plan could be either the primary or secondary payer according to
Medicare's Secondary Payer rules. To determine the order plans should pay, for expenses covered by two or
more plans with a COB feature, an order of benefit determination has been established as follows:
1. Non-Dependent or a Dependent. The plan that covers the person other than as a dependent, for example
as an employee, member, subscriber, enrollee, or retiree is primary. The plan that covers the person as a
dependent is secondary. However, this could change if the person is eligible for Medicare primary benefits.
The Medicare rules for employment status could apply making the dependent plan primary over the plan of
a person without employment status.
2. Child Covered under More than One Plan. The following order of benefits is used when a child is
covered by more than one Plan.
a. The primary plan is the plan of the parent whose birthday is earlier in the year if the parents are
married, not separated (whether or not they have ever been married), or a court decree awards joint
custody without specifying that one party has the responsibility to provide health care coverage. If
both parents have the same birthday, the plan that covered either of the parents longer is primary.
b. When specific terms of a court decree state that one parent is responsible for the child's health care
expenses or health care coverage and the plan of that parent has actual knowledge of those terms then
that plan is primary. This rule applies to claim determination periods or plan years commencing after
the plan is given notice of the court decree.
c. If the parents are not married, or are separated (whether or not they have ever been married) or are
divorced; the order of benefits is the plan of the custodial parent, then the plan of the Spouse of the
custodial parent, then the plan of the non-custodial parent and then the plan of the Spouse of the non-
custodial parent. The custodial parent is the parent awarded custody by a court decree. Without a
court decree, it is the parent with whom the child resides more than half the Calendar Year without
regard to temporary visitations.
3. Active/Inactive Employee. The benefits of a plan that covers a person as an employee who is neither laid
off nor retired are determined before the plan that covers that person as a laid off or retired employee. The
same would hold true for that person's dependents.
4. Continuation Coverage. If a person elects or is covered under continuation of coverage pursuant to federal
or state laws, such as COBRA or USERRA, and is also covered under another plan, the order of benefit
rules change. The plan that provides coverage for the individual as an employee, member, subscriber,
enrollee, or retiree is primary for that person and/or that person's dependents. The plan providing
continuation coverage is secondary.
If the preceding order of benefit rules fail to establish the primary plan(s), then the plan that has covered the
person for the longer time will consider its plan benefits first.
If according to the above rules, This Plan is secondary and another health plan's rules conflict making This Plan
primary, This Plan will use the National Association of Insurance Commissioners (NAIC) Model Regulation
and any court cases to determine the validity of the conflicting rules.
