2021 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 18
When there is a conflict in the Plans’ Coordination of Benefit rules, this Plan will never pay more than 50% of
allowable charges when paying as the secondary Plan.
This Plan will not pay first if the Covered Person would have been eligible under another primary Plan but for
the failure of the Covered Person to meet the technical requirements of the other Plan (such as obtaining preauthorization). In that instance, this Plan shall pay as if it were the secondary Plan, but in no event shall this
Health Care Plan pay more than 50% of the allowable charges.
Coordination of Benefits may operate to reduce the total amount of benefits otherwise payable during any claim
determination period with respect to a Covered Person under this Health Care Plan. When the benefits of this
Health Care Plan are reduced, each benefit is reduced proportionately. The reduced amount is then charged
against any applicable benefit limit of this Health Care Plan.
When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value
of each service rendered will be considered to be both an Allowable Expense and a benefit paid.
If the amount of the payment made by this Health Care Plan is more than it should have been due to lack of
information or error, or should have been paid by another Plan, the Claims Administrator, on behalf of the Health
Care Plan, has the right to recover the amount paid from one or more of the following:
The person this Health Care Plan has paid;
The Covered Person;
Providers of care;
Other organizations; or
Payment to Other Carriers
Whenever payments, which should have been made under this Health Care Plan in accordance with the above
provisions, have been made, this Health Care Plan will have the right to pay any organization making those
payments any amounts it determines to be warranted in order to satisfy the intent of the above provisions.
Amounts paid in this manner will be considered to be benefits paid under this Health Care Plan and, to the
extent of these payments, this Health Care Plan will be fully discharged from liability.
Effect of Medicare
In accordance with Federal Medicare regulations, the following is a brief explanation of the Medicare
guidelines, not to be considered all inclusive.
Working Aged Benefits
Employers with 20 or more Employees: This Health Care Plan will be primary when an active Employee
or Spouse is age sixty-five (65) and over.
Employers with 100 or more Employees: This Health Care Plan will be primary when an active Employee
or Dependent is disabled and covered by Medicare.
Disability Due to End Stage Renal Disease (ESRD)
For Employees or Dependents under age sixty-five (65), if Medicare eligibility is due solely to End Stage
Renal Disease (ESRD), the Health Care Plan will be primary only during the first thirty (30) months of
Medicare coverage. Thereafter, the Health Care Plan will be secondary with respect to Medicare coverage.