• Blue Cross Blue Shield »
• Kaiser »
• Humana Health »

• Medicare Advantage Health Plans »
• Georgia Supplemental Medigap Insurance »
• Blue Cross Blue Shield »
• Humana »

Coordination of Georgia Health Insurance Benefits

If you, your Spouse, or your Dependents have duplicate coverage under another BlueChoice Healthcare Plan BCBSGA plan, any other group medical expense coverage, or any local, state or governmental plan (except school accident insurance coverage or Medicaid), then benefits payable under this Plan will be coordinated with the benefits payable under the other plan. The total benefits paid by both plans will not exceed 100% UCR, the per diem negotiated fee or the contracted amount.

Allowable Expense means any necessary, reasonable and customary expense at least a portion of which is covered under at least one of the plans covering the person for whom the claim is made. The claim determination period is the calendar year.

Order of Benefit Determination
When you have duplicate coverage, claims will be paid as follows:

• Automobile Insurance
  Medical benefits available through automobile insurance coverage will be determined before that of any other plan if the automobile coverage has either no order of benefit determination rules or it has rules which differ from those permitted under applicable Georgia Insurance Regulations.
• Non-Dependent/Dependent
  The benefits of the plan which covers the person as an Employee (other than as a Dependent) are determined before those of the plan which covers the person as a Dependent.
• Dependent Child/Parents Not Separated or Divorced
  Except as stated below, when this Plan and another plan cover the same child as a Dependent of different persons, called "parents":
• • The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year.
  • If both parents have the same birthday, the benefits of the plan which covered the parent longer are determined before those of the plan which covered the other parent for a shorter period of time.
  • However, if the other plan does not have the rule described above, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefits.
• Dependent Child/Parents Separated or Divorced
  If two or more plans cover a person as a Dependent child of divorced or separated parents, benefits for the child are determined in this order:
• • first, the plan of the parent with custody of the child;
  • then, the plan of the Spouse of the parent with custody of the child; and
  • finally, the plan of the parent not having custody of the child.
• However, if the specific terms of a court decree state that one of the parents is responsible for the child's health care expenses, and the company obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. This paragraph does not apply with respect to any claim determination period or plan year during which any benefits are actually paid or provided before the company has that actual knowledge.
• Joint Custody
  If the specific terms of a court decree state that the parents shall have joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child shall follow the order of benefit determination rules outlined above for "Dependent Child/Parents not Separated or Divorced."
• Active/Inactive Employee
  The benefits of a plan that covers a person as an Employee who is neither laid off nor retired (or as that Employee's Dependent) are determined before those of a plan that covers that person as a laid-off or retired Employee (or as that Employee's Dependent). If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule is ignored.
• Longer/Shorter Length of Coverage
  If none of the above rules determines the order of benefits, the benefits of the plan which covered an Employee or Participant longer are determined before those of the plan that covered that person for the shorter time.
• Effect on the Benefits of this Plan
  This section applies when, in accordance with the Order of Benefit Determination Rules, this Plan is a secondary Plan to one or more other plans. In that event the benefits of this Plan may be reduced under this section. Such other plan or plans are referred to as "the other plan" below.
• Reduction in this Plan's Benefits
  The benefits of this Plan will be reduced when the sum of:
• • the benefits that would be payable for the Allowable Expenses under this Plan in the absence of this provision; and
  • the benefits that would be payable for the Allowable Expenses under the other plans, in the absence of provisions with a purpose like that of this provision, whether or not claim is made, exceed those Allowable Expenses in a claim determination period. In that case, the benefits of this Plan will be reduced so that they and the benefits payable under the other plans do not total more than those Allowable Expenses.
• When the benefits of this Plan are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of this Plan.
• Miscellaneous Rights
• • Right to Receive and Release Necessary Information
    Certain facts are needed to apply these rules. The Plan have the right to decide which facts are needed. The Plan Administrator may get needed facts from or give them to any other organization or person as necessary to coordinate benefits. The Plan Administrator need not tell, or get the consent of, any person to do this. Each person claiming benefits under this Plan must give the Claims Administrator any facts needed to pay the claim.
  • Facility of Payment
    A payment made under another plan may include an amount which should have been paid under this Plan. If it does, the Plan Administrator may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under this Plan. The Plan Administrator will not have to pay that amount again.
  • Right of Reimbursement
    If the amount of the payment made by the Claims Administrator is more than it should have paid under this provision, the Claims Administrator may recover the excess from one or more of:
  • • the persons the Claims Administrator has paid or for whom the Claims Administrator has paid,
    • insurance companies, or
    • other organizations.