Page 90 - Aegion PPO SPDs
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Rule 3 - Active Employee or Retired or Laid-off Employee. The Plan that covers You as an active
Employee, that is, an Employee who is neither laid off nor retired, is the Primary Plan. The Plan also
covering You as a retired or laid-off Employee is the Secondary Plan. The same would hold true if You are
a Dependent of an active Employee and You are a Dependent of a retired or laid-off Employee. If the other
Plan does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule is
ignored. This rule does not apply if “Rule 1 - Non-Dependent or Dependent” can determine the order of
benefits.
Rule 4 - COBRA. If You are covered under COBRA or under a right of continuation provided by other
federal law and are covered under another Plan, the Plan covering You as an employee, member,
subscriber or retiree or covering You as a Dependent of an employee, member, subscriber or retiree is the
Primary Plan and the COBRA or other federal continuation coverage is the Secondary Plan. If the other
Plan does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule is
ignored. This rule does not apply if “Rule 1 - Non-Dependent or Dependent” can determine the order of
benefits. This rule does not apply when the person is covered either: (a) as a non- dependent under both
Plans (i.e. the person is covered under a right of continuation as a qualified beneficiary who, on the day
before a qualifying event, was covered under the group health plan as an employee or as a retired employee
and is covered under his or her own Plan as an employee, member, subscriber or retiree); or (b) as a
Dependent under both plans (i.e. the person is covered under a right of continuation as a qualified
beneficiary who, on the day before a qualifying event, was covered under the group health plan as a
dependent of an employee, member or subscriber or retired employee and is covered under the other plan
as a dependent of an employee, member, subscriber or retiree).
Rule 5 - Longer or Shorter Length of Coverage. The Plan that covered You longer is the Primary Plan
and the Plan that covered You the shorter period of time is the Secondary Plan.
Rule 6. If the preceding rules do not determine the order of benefits, the Allowable expenses will be shared
equally between the Plans meeting the definition of Plan. In addition, This Plan will not pay more than it
would have paid had it been the Primary Plan.
Effect On The Benefits Of This Plan
When a Member is covered under two or more Plans which together pay more than this Plan’s benefits,
the Plan will pay this Plan's benefits according to the Order of Benefit Determination Rules. This Plan's
benefit payments will not be affected when it is Primary. However, when this Plan is Secondary under the
Order of Benefit Determination Rules, benefits payable by this Plan will be reduced by the combined
benefits of all other Plans covering You or Your Dependent.
When the benefits of this Plan are reduced, each benefit is reduced in proportion. It is then charged against
any applicable benefit limit of this Plan. If this Plan is secondary, the combined benefits of this Plan and
the other Plan will never exceed what would have been provided by this Plan if primary. No benefits will
be provided by this Plan when the amount paid by the other Plan is equal to or greater than the amount this
Plan would have paid if Primary.
If You are enrolled in two or more Closed panel plans and if, for any reason, including the provision of
service by a non-panel Provider, benefits are not payable by one Closed panel plan, COB will not apply
between that Plan and other Closed panel plans.
Right To Receive And Release Needed Information
Certain facts about health care coverage and services are needed to apply these COB rules and to
determine benefits payable under This Plan and other Plans. The Claims Administrator may get the facts
it needs from or give them to other organizations or persons for the purpose of applying these rules and
determining benefits payable under This Plan and other Plans covering the person claiming benefits. The
Claims Administrator need not tell, or get the consent of, any person to do this. Each person claiming
benefits under This Plan must give the Claims Administrator any facts the Claims Administrator need to
apply those rules and determine benefits payable.
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Employee, that is, an Employee who is neither laid off nor retired, is the Primary Plan. The Plan also
covering You as a retired or laid-off Employee is the Secondary Plan. The same would hold true if You are
a Dependent of an active Employee and You are a Dependent of a retired or laid-off Employee. If the other
Plan does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule is
ignored. This rule does not apply if “Rule 1 - Non-Dependent or Dependent” can determine the order of
benefits.
Rule 4 - COBRA. If You are covered under COBRA or under a right of continuation provided by other
federal law and are covered under another Plan, the Plan covering You as an employee, member,
subscriber or retiree or covering You as a Dependent of an employee, member, subscriber or retiree is the
Primary Plan and the COBRA or other federal continuation coverage is the Secondary Plan. If the other
Plan does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule is
ignored. This rule does not apply if “Rule 1 - Non-Dependent or Dependent” can determine the order of
benefits. This rule does not apply when the person is covered either: (a) as a non- dependent under both
Plans (i.e. the person is covered under a right of continuation as a qualified beneficiary who, on the day
before a qualifying event, was covered under the group health plan as an employee or as a retired employee
and is covered under his or her own Plan as an employee, member, subscriber or retiree); or (b) as a
Dependent under both plans (i.e. the person is covered under a right of continuation as a qualified
beneficiary who, on the day before a qualifying event, was covered under the group health plan as a
dependent of an employee, member or subscriber or retired employee and is covered under the other plan
as a dependent of an employee, member, subscriber or retiree).
Rule 5 - Longer or Shorter Length of Coverage. The Plan that covered You longer is the Primary Plan
and the Plan that covered You the shorter period of time is the Secondary Plan.
Rule 6. If the preceding rules do not determine the order of benefits, the Allowable expenses will be shared
equally between the Plans meeting the definition of Plan. In addition, This Plan will not pay more than it
would have paid had it been the Primary Plan.
Effect On The Benefits Of This Plan
When a Member is covered under two or more Plans which together pay more than this Plan’s benefits,
the Plan will pay this Plan's benefits according to the Order of Benefit Determination Rules. This Plan's
benefit payments will not be affected when it is Primary. However, when this Plan is Secondary under the
Order of Benefit Determination Rules, benefits payable by this Plan will be reduced by the combined
benefits of all other Plans covering You or Your Dependent.
When the benefits of this Plan are reduced, each benefit is reduced in proportion. It is then charged against
any applicable benefit limit of this Plan. If this Plan is secondary, the combined benefits of this Plan and
the other Plan will never exceed what would have been provided by this Plan if primary. No benefits will
be provided by this Plan when the amount paid by the other Plan is equal to or greater than the amount this
Plan would have paid if Primary.
If You are enrolled in two or more Closed panel plans and if, for any reason, including the provision of
service by a non-panel Provider, benefits are not payable by one Closed panel plan, COB will not apply
between that Plan and other Closed panel plans.
Right To Receive And Release Needed Information
Certain facts about health care coverage and services are needed to apply these COB rules and to
determine benefits payable under This Plan and other Plans. The Claims Administrator may get the facts
it needs from or give them to other organizations or persons for the purpose of applying these rules and
determining benefits payable under This Plan and other Plans covering the person claiming benefits. The
Claims Administrator need not tell, or get the consent of, any person to do this. Each person claiming
benefits under This Plan must give the Claims Administrator any facts the Claims Administrator need to
apply those rules and determine benefits payable.
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