2021 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 16
The benefits of the Plan which covers the individual as an Employee (that is, other than as a dependent)
are determined before those of the Plan which covered the individual as a dependent.
The rules for the order of benefits for a dependent child when parents are not separated or divorced are as
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 where the word “birthday” refers
only to month and day in a calendar year, not the year in which the person was born.
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.
If the other Plan does not have the rules described above relating to the parents’ birthday, but
instead has a rule based upon the gender of the parent, and the Plans do not agree on the order of
benefits, the rule based upon the gender of the parent will determine the order of benefits.
If the 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 the custody of the child;
Then, the Plan of the parent not having custody of the child.
If the specific terms of a court decree state that one of the parents is responsible for the health care
expenses of the child, and the entity 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. The Plan
of the other parent shall be the secondary Plan. 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 entity has that actual knowledge.
If the specific terms of the court decree state that the parents shall share 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.
The benefits of a Plan which 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 which 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 the Plans
do not agree on the order of benefits, this rule is ignored.
If none of the above rules determines the order of benefits, the benefits of the Plan which covered an
Employee longer are determined before those of the Plan which covered that person for the shorter term.
To determine the length of time a person has been covered under a Plan, two Plans shall be treated as one
if the person was eligible under the second Plan within twenty-four hours after the first ended. The start of
a new Plan does not include a change in the amount of scope of a Plan’s benefits, a change in the entity
which pays, provides or administers the Plan’s benefits, or a change from one type of Plan to another (such
as, from a single employer plan to that of a multiple employer plan).
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.