Third Party Liability Under Georgia's Lumenos Health Insurance Plan

In certain situations your benefits under the Plan and the Lumenos plan option will be coordinated with other benefits. Refer to the sections below for additional information:

• Coordination of Benefits (COB)
• Integrating Benefits with Medicare
• Subrogation

Coordination of Benefits (COB)

If you are eligible for benefits under another group health care plan, such as your spouse's plan or another employer's plan, the two plans will coordinate their benefit payments so the combined payments do not exceed your actual expenses. This provision is called coordination of benefits (COB). The Plan uses a COB method called "non-duplication of benefits."

For more information on COB, see:

• How COB Works
• COB "Birthday Rule"
• Right to Recover

How COB Works

Under COB provisions, one group plan has "primary" responsibility and pays first. The other group plan has "secondary" responsibility and considers any additional benefits not covered by the primary carrier. Therefore, if the Plan is:

• primary - it pays expenses as if no other insurance were involved
• secondary - it pays benefits only if you have not already received the full amount the Plan would pay if it were primary

if the benefit is for...	Then...
You	The Plan is primary for you, as an employee
You as a COBRA participant continuing benefits under another plan	COBRA coverage will be primary for limits and exclusions under the other plan
Your spouse	The Plan is always the secondary payer if he or she is covered through another employer's plan
Your dependent children	The primary plan for your dependent children is determined by the COB "Birthday Rule" except where child is covered as an employee under another employer plan. In that case, the plan covering the dependent as an employee will be primary (without regard to the Birthday Rule)

If the other group benefit plan does not have a COB provision, these rules will not apply. In that case, the other group plan is automatically primary.

You should always file a claim with the primary plan first and then submit a copy of what the primary plan has paid or denied (along with copies of the same itemized expenses) to the secondary plan. This will avoid delays in claims processing and will ensure that you are reimbursed for the full amount to which you are entitled.

COB "Birthday Rule"

Under this rule, primary coverage for your dependent children will be the plan of the parent whose birthday occurs first in the calendar year. For example, if your spouse's birthday is in March and your birthday is in October, your spouse's plan will provide primary coverage for your children. If a decision cannot be made based on the birthday rule, the plan that has covered the individual the longest will be primary.

Primary coverage for a dependent child whose parents are separated or divorced will be determined in the following order, without regard to the birthday rule:

1. The plan of the parent with custody of the child.
2. The plan of the stepparent whose spouse has custody of the child - if the parent with custody has remarried.
3. The plan of the parent not having custody of the child.

NOTE: If a court decree declares one parent responsible for a child's health care expenses, payment will be made first under that parent's plan.

Right to Recover

If the Plan makes larger payments than are necessary under this COB provision or under any other provision, the Plan Administrator has the right to recover the excess payments from any insurance company, any organization, and/or any persons for whom those payments were made.

The Claims Administrator also may pay another organization an amount that it determines is warranted, if the other organization or group plan pays benefits that should have been paid under the Plan.

The Plan also has the right to receive and release necessary information to determine whether coordination of benefits or any similar provisions apply to a claim. By participating in this Lumenos plan option, you agree to furnish any information that the Plan Administrator requires in order to enforce these provisions.

Integrating Benefits with Medicare

As a general rule, if you or your covered dependent becomes eligible for Medicare benefits, there are rules that determine whether the Plan pays benefits first, or whether Medicare is primary.

If you are an active employee covered by the Plan, the Plan would be primary for you and your covered dependent who is entitled to Medicare (for example, due to a disability or being age 65 or older). If you are disabled and not actively working, the Plan would be primary for you and any covered dependents who may be entitled to Medicare for the first six calendar months of your disability period. After the six-month period, if you are not actively working at the Company, Medicare pays benefits first for you and any covered dependents (if they are also eligible for Medicare).

During the time the Plan pays benefits first, you should submit a claim for any remaining expenses not covered by the Plan to Medicare. (Incidentally, you should apply for Social Security disability income benefits during the fifth month of disability to make sure you have no gaps in income protection.) During the time Medicare pays benefits first, you should first submit claims to Medicare for payment.

Medical Coverage for Individuals with End-Stage Renal Disease

In all situations involving end-stage renal disease (ESRD) - regardless of age or Medicare status - the Plan will be the primary payer of medical benefits during the first 30 months the individual is eligible for Medicare benefits as a result of End Stage Renal Disease. Thereafter, Medicare will be the primary payer of medical benefits for the individual and the Plan will be secondary payer.