2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 17
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.
Recovery
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:
(1)
The person this Health Care Plan has paid;
(2)
The Covered Person;
(3)
Providers of care;
(4)
Insurance companies;
(5)
Other organizations; or
(6)
Another Plan.
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.
(1)
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.
(2)
Disabled Employees/Spouses
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.
(3)
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.
If an Employee or Dependent is under age sixty-five (65) when Medicare eligibility is due solely to ESRD, and
the individual attains age sixty-five (65), the Health Care Plan will be primary for a full thirty
(30) months (or 33 months, depending upon whether a transplant or self-dialysis is involved) from the date of
ESRD eligibility. Thereafter, Medicare will be primary and the Plan will be secondary.
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