2021 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 15
COORDINATION OF BENEFITS
There is no Coordination of Benefits for prescription drug charges.
If a Covered Person is covered under more than one Health Care Plan as defined below, including this Health Care
Plan, benefits will be coordinated. The benefits payable under this Health Care Plan for any Claim Determination
Period, will be either its regular benefits or reduced benefits which, when added to the benefits of the other Plan,
may equal 100% of the Allowable Expenses defined below.
Allowable Expenses: Any Medically Necessary, Usual and Customary item of expense Incurred by a Covered
Person which is covered at least in part under this Health Care Plan.
Claim Determination Period: A Calendar or Plan Year or that portion of a Calendar or Plan Year during which the
Covered Person for whom a Claim is made has been covered under this Health Care Plan.
Plan: For purposes of this Coordination of Benefits section and the Reimbursement Rights section, Plan shall mean
any plan or policy under which benefits or services are provided by:
Group, blanket or franchise insurance coverage;
Any group Hospital service prepayment, group medical or dental service prepayment, group practice or
other group prepayment coverage;
Group coverage under labor-management trusteed plans, union welfare plans, employer organization plans
or employee benefits plans;
Coverage under Medicare and any other governmental program that the Covered Person is liable for payment,
except state-sponsored medical assistance programs and TRICARE, in which case this Plan pays primary for
Coverage provided through a school or other educational institution;
Coverage under any Health Maintenance Organization (HMO);
Coverage provided by no-fault auto insurance, by whatever name it is called, when not prohibited by law; or
Coverage provided by Workers’ Compensation.
When medical payments are available under vehicle insurance, this Health Care Plan shall pay excess benefits
only, without reimbursement for vehicle plan deductibles. This Health Care Plan shall always be considered the
secondary carrier regardless of the individual’s election under PIP (personal Injury protection) coverage with the
Order of Benefit Determination
When a Covered Person is covered by this Health Care Plan and another Plan, the Plans will coordinate benefits
when a Claim is made.
When a Claim is made, the Plan that pays first (or the primary Plan) will pay as if there were no other Plan involved.
A Plan that does not include a coordination of benefits provision may not take the benefits of another Plan into
account when it determines benefits.
The secondary Plan may take the benefits of another Plan into account only when it is secondary to that Plan. The
secondary Plan will adjust its benefits so that the total benefits paid by both Plans will not exceed 100% of the
Allowable Expenses. Neither Plan pays more than it would without the Coordination of Benefits provision.