PEF Dental Plan
This dental plan provides benefits for most types of dental services. Your level of dental benefits is known as the GHI Preferred Dental Plan. This document is your Certificate of Insurance.
Coordination Of Benefits
Coordination of Benefits is the method by which enrollees who are covered by more than one insurance company cannot collect more than the amount of expenses they actually incurred. Briefly, this is accomplished by determining what are known as the "primary" and "secondary" insurance companies. The plan covering the patient as an enrollee (the "primary" carrier) pays before the plan covering the patient as a dependent (the "secondary" carrier). The "primary" plan calculates benefits as though duplicate coverage did not exist. The "secondary" plan then reimburses the subscriber for the difference between what the "primary" plan has paid, and 100 percent of actual expenses, provided that this difference does not exceed the benefits that the plan would have paid in the absence of duplicate coverage.
In addition, for enrollees who are covered by two GHI policies, GHI will coordinate their dental benefits. In order to determine which plan is primary, certain rules have been set. GHI will follow these rules. These rules apply whether or not you make a claim under both plans. See below for rules of coordination.
Rules of Coordination:
Plan A plan is a form of group coverage other than Medicaid for which these rules of coordination of benefits are allowed.
A plan may include:
- Group insurance, group or group remittance subscriber contracts.
- Self-insured group coverage.
- Prepayment group coverage, including HMOs, group practice and individual practice plans.
- Blanket contracts, except blanket school accident coverages or such coverages issued to a substantially similar group, where the policyholder pays the premium.
- The medical benefits coverage in group and individual mandatory automobile no-fault contracts.
If the patient is a dependent child covered under the plans of both parents, the plan of the parent whose birthday falls earlier in the year will be primary. If both parents have the same birthday (only the month and the date are considered), the plan that has covered the parent the longest will be primary. However, if one plan does not have this rule, but instead has a rule based on the gender of the parent and, as a result, the plans do not agree on which is primary, then the father's plan will be primary.
If no other criteria apply, the plan covering you the longest is primary. However, the plan covering you as a laid-off or retired employee, or as a dependent of such a person, shall be secondary and the plan covering you as an active employee or a dependent of any active employee shall be primary as long as the other plan has a COB provision similar to this one.
Special Rules for Dependents of Separated or Divorced Parents
- If there is a court decree that imposes financial responsibility for the health care expenses of the dependent child on one parent, that parent's plan is primary. That plan must have actual knowledge of the decree. GHI has the right to request a copy of the portion of the decree pertaining to the health care expenses of the dependent child.
- If there is no court decree, the plan covering the parent with custody of a dependent child is primary.
- If the parent with custody of a dependent child remarries, that parent's plan is primary. The step-parent's plan is secondary. The plan covering the parent without custody is tertiary.
Plans with Different COB Rules:
Group plans are written in many states. Not all states or groups follow the same rules. Some plans have language that states that the plan is an "excess" plan or is "always secondary". In that event, GHI will coordinate as set forth below.
- If GHI would be primary under the rules listed above, it will pay primary benefits.
- If GHI would be secondary under the rules listed above, it will pay its benefits first. However, the amount of benefits paid will be determined as if GHI was the secondary plan. Such payment will be the limit of GHI's liability.
- In order to determine benefits under (b), GHI may need information from the other plan. If that plan does not provide the information necessary for GHI to determine benefits within thirty (30) days of a request to do so, GHI will assume the benefits of the other plan are identical to GHI's. Benefits will then be paid accordingly. Adjustments will be made if information becomes available as to the benefits of the other plan.
In certain situations, GHI may find that it has paid more than should have been paid under coordination of benefits. If GHI pays you more than you should have been paid, it has the right to recover the overpayment. GHI may recover the overpayment from you or any other person, insurance company, or other organization which gained from the overpayment. You must help GHI to recover any overpayment. This may mean filing claim forms with another company. It may also mean endorsing checks over to GHI. GHI has the right to decide which facts it needs in order to coordinate benefits.
GHI may get needed facts from or give needed facts to any organization or person. GHI need not tell or obtain the consent of any person to do this, except as required by the New York State Fair Credit Reporting Act. You must give GHI any facts it needs to process a claim and coordinate benefits.