If you or members of your family are covered by more than one group health plan, benefits are coordinated so that you do not receive greater benefits than your actual health care expenses.
The “primary plan” pays first, regardless of any amount payable under any other plan.
The “secondary plan” will adjust its benefit payment so that the total benefit payable does not exceed 100% of the allowable expense incurred.
The Fund will never pay as primary or pay first if you have another group carrier as primary.
The Fund will only pay expenses once you become eligible for Medicare as if you had enrolled in Medicare Parts A & B.
Members of a family may be covered under more than one group health plan, possibly resulting in duplication of health care coverage. To avoid payment for the same benefit as a result of this duplication, the medical, dental, prescription drug and vision benefits provided by this Plan are coordinated with similar benefits payable under other plans, including Medicare.
What You Need to Do
When you (or a preferred provider) submit a claim for benefits, you must report all other group health insurance you have to avoid unnecessary payment from this Plan. Determine which Plan is “primary” for the covered person claiming benefits by reviewing the below. You will need to file the claim with the Primary Plan first. You may then file a claim with the “Secondary” Plan to pay for any eligible outstanding charges.
You must report other group health insurance coverage you have on the claim form that you submit when you request benefits from the Plan. In order to assure proper administration of the coordination of benefits provisions of the Plan, the Board of Trustees reserves the right to:
- Request updated other insurance information and suspend benefits for your dependents if the information is not received after three attempts;
- Exchange information with other parties regarding your and your dependents’ other insurance coverage, to the extent necessary to provide for the coordination of benefits under the Plan;
- Make payments to other parties in satisfaction of Plan liabilities; and
- Recover any excess payments made.
Methods of Coordination
If you or your dependents have other health care coverage in addition to the coverage provided under this Plan, benefits are coordinated by looking first to what is called the “primary plan.” If any charges remain after the primary plan has paid benefits, then the secondary plan will process those remaining claims.
If you have other coverage, which is determined to be primary, the Plan will pay as secondary. For example, if your spouse has other group insurance as an employee and is covered as a dependent on this Plan, the coverage for your spouse under this Plan is secondary and the coverage under your spouse’s employer-sponsored plan is primary.
Order of Benefit Determination Rules
A plan that does not have a coordination of benefits rule consistent with this section shall always be the primary plan. If the plan does have a coordination of benefits rule consistent with this section, the first of the following rules that applies to the situation is the applicable rule:
- The plan that covers the individual as an enrollee or an employee shall be the primary plan and the plan that covers the individual as a dependent shall be the secondary plan;
- If the individual is a dependent child whose parents are not divorced or legally separated, the primary plan shall be the plan that covers the parent (as an enrollee or employee) whose birthday falls first in the calendar year;
- If the individual is the dependent of divorced or separated parents, benefits for the dependent shall be determined in the following order:
- first, if a court decree states that one parent is responsible for the child’s healthcare expenses or health coverage and the plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge;
- then, the plan of the parent with custody of the child;
- then, the plan of the spouse of the parent with custody of the child;
- then, the plan of the parent not having custody of the child, and
- finally, the plan of the spouse of the parent not having custody of the child.
- The plan that covers the individual as an active employee (or as that employee’s dependent) shall be the primary plan and the plan that covers the individual as a laid-off or retired employee (or as that employee’s dependent) shall be the secondary plan. If the other plan does not have a similar provision and, as a result, the plans cannot agree on the order of benefit determination, this paragraph shall not apply.
- The plan that covers the individual under a right of continuation that is provided by federal or state law shall be the secondary plan and the plan that covers the individual as an active employee or retiree (or as that employee’s dependent) shall be the primary plan. If the other plan does not have a similar provision and, as a result, the plans cannot agree on the order of benefit determination, this paragraph shall not apply.
- If one of the plans that cover the individual is issued out of the state whose laws govern this plan, and determines the order of benefits based upon the gender of a parent, and as a result, the plans do not agree on the order of benefit determination, the plan with the gender rules shall determine the order of benefits.
- If none of the above rules determines the order of benefits, the plan that has covered an individual for the longer period of time shall be primary.
Steps to Follow if You or Your Family Members are Covered by More Than One Plan
Coordination of Benefits may result in lower out-of-pocket expenses to you and members of your family if you follow the coordination of benefit procedures for this Plan and any other plan for which a family member may be covered.
If EWTF is primary plan:
- Submit the claim using the procedures described in the applicable section of this SPD;
- Upon receipt of EWTF Explanation of Benefits (EOB), submit a copy of original claim and EOB to spouse’s health plan.
If Spouse’s health plan is primary:
- Submit a copy of the claim to that plan, following that plan’s guidelines for submittal;
- Upon receipt of the other plan’s Explanation of Benefits (EOB), submit copy of both the EOB and the claim to EWTF.
Coordination Of Benefits With Medicare
Medicare Parts A & B
When you reach age 65 or become disabled, you are eligible for hospital insurance benefits (“Part A”) and supplementary medical insurance (“Part B”) under Medicare. If you are a Medicare-eligible retired employee, or a Medicare-eligible dependent of a retiree, Medicare is the primary plan, and this Plan is the secondary plan to the extent of the Supplemental Medicare Benefits described on page 91. In all other circumstances, this Plan is the primary plan and Medicare is secondary.
The Plan’s annual deductible does not apply to Medicare-eligible retirees.
There are special rules for Medicare-eligible individuals with end-stage renal disease (ESRD). Please contact the Fund Office for more information.
Note: If you are a Retiree, you and your dependents are responsible for enrolling in the Medicare Parts A and B program promptly. Otherwise, you will not receive the additional benefits and coverage for which you are eligible. This Plan does not cover any expenses Medicare would have covered if you, or your Medicare-eligible spouse, had enrolled in a timely manner. To enroll in Medicare, visit an office of the Social Security Administration, or enroll online, about three months before your 65th birthday.
If you are covered by both this Plan and TRICARE, this Plan is the primary plan and TRICARE is the secondary plan.
Motor Vehicle No-Fault Coverage Required By Law
If you are covered by both this Plan and any motor vehicle no-fault coverage that is required by law, the motor vehicle no-fault coverage pays first, and this Plan pays second.
This Plan does NOT provide benefits if the medical expenses are covered by workers’ compensation or occupational disease law.
The Plan complies with the requirements of ERISA §609(b) regarding participants and beneficiaries eligible for Medicaid. The Plan shall not reduce or deny benefits for any participant or dependent to reflect the fact that such an individual is eligible to receive medical assistance under a state Medicaid plan. Under state and federal law, should a participant or dependent covered under the Plan be entitled to payment of a claim under the Plan, and all or part of that claim has been paid by Medicaid, then the state is subrogated to the participant or dependent’s right to payment under the Plan to the extent of the amount paid by Medicaid, and reimbursement under the Plan will be made in that amount directly to the state.