SSMC Employee Health Benefit Plan
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F. Facility of Payment
A payment made under another plan may include an amount that should have been paid under This Plan. If it
does, the Claims Administrator may pay the amount to the organization that made that payment. That amount
will then be treated as though it was a benefit paid under the Plan. The Plan Administrator will not have to pay
that amount again. The term "payment made" includes providing benefits in the form of services in which case
"payment made" means reasonable cash value of the benefits provided as services.
G. Right of Recovery
If the amount of the payments made by the Claims Administrator is more than it should have paid under this
COB provision, it may recover the excess from one or more of the following:
1. The Enrollee, dependent for whom it has paid or the Provider to whom benefits were paid;
2. Insurance companies;
3. Self-Funded claims administrators; plan administrators, or plan sponsors; or
4. Other organizations or entities.
H. Examples of COB Order of Benefits
1. I am eligible for SSMC Plan benefits as an Employee and am also eligible as a retiree under the ABC
Mfg. health plan. (I am not eligible for Medicare). Which plan pays first?
Your active Plan is primary over your retired plan. SSMC Plan would pay first.
2. I am eligible for SSMC Plan coverage as an Employee. My Spouse is enrolled in my family coverage.
She is covered as a retiree under XYZ, Inc. Plan. Neither of us are eligible for Medicare. Which plan
pays first for my health claims? For my Spouse's health claims?
a. Health Claims for you:
SSMC active Plan pays first.
XYZ, Inc. retired plan pays second.
b. Health Claims for Spouse:
XYZ, Inc. retired plan pays first.
SSMC active Plan pays second.
3. I am eligible for SSMC Plan benefits as an Employee and also eligible as a retiree under the ABC Mfg.
health plan. I have family coverage under both plans. My Spouse also covers me and our dependent
children under his or her group plan through XYZ, Inc. (We are not eligible for Medicare) My birthdate
is July 10, 1950. My Spouse was born June 15, 1951. What is the order of benefit determination for
myself, my Spouse and my children?
a. Health Claims for yourself. Your Health plans would pay before the health plan of your Spouse.
Order of benefit determination is:
SSMC active Plan pays first.
ABC Mfg. retired plan pays second.
XYZ, Inc. active plan for Spouse pays last
b. Health Claims for Spouse. Your Spouse's plan pays before your health plans. Order of benefit
determination is:
XYZ, Inc. active plan for Spouse pays first.
SSMC active Plan pays second.
ABC Mfg. retired plan pays last.
