Page 53 - Dental Benefit Plan Summary

TEXAS MUTUAL INSURANCE COMPANY DENTAL PPO PLAN

do not agree on the order of benefits, this rule is ignored. Coverage provided an
individual as a retired worker and as a Dependent of an actively working spouse will
be determined under the rule for "Non-Dependent or Dependent"
- Continuation coverage. If a person whose coverage is provided under a right of
continuation provided by federal or state law also is covered under another Coverage
Plan, the Coverage Plan covering the person as an employee, member, Participant or
retiree (or as that person's Dependent) is primary, and the continuation coverage is
secondary. If the other Coverage Plan does not have this rule, and if, as a result, the
Coverage Plans do not agree on the order of benefits, this rule is ignored.
- Longer or shorter length of coverage. The Coverage Plan that covered the person
as an employee, member, Participant or retiree longer is primary.
- If the preceding rules do not determine the primary Coverage Plan, the allowable
expenses will be shared equally between the Coverage Plans meeting the definition of
Coverage Plan under this provision. In addition, this Coverage Plan will not pay
more than it would have paid had it been primary.

Effect on the Benefits of This Coverage Plan
When this Coverage Plan is secondary, it may reduce its benefits so that the total benefits
paid or provided by all Coverage Plans during a claim determination period are not more
than 100 percent of total allowable expenses.

When this Coverage Plan is the secondary carrier, this Coverage Plan will only pay the
difference between what this Coverage Plan would have paid as primary minus what the
other carrier paid.

■ If a covered person is enrolled in two or more closed panel Coverage Plans and if, for
any reason, including the provision of service by a non-panel provider, benefits are not
payable by one closed panel Coverage Plan, COB will not apply between that Coverage
Plan and other closed panel Coverage Plans.

■ This Coverage Plan reduces its benefits as described below for Covered Persons who are
eligible for Medicare when Medicare would be the primary Coverage Plan.
Medicare benefits are determined as if the full amount that would have been payable
under Medicare was actually paid under Medicare, even if:
- The person is not enrolled for Medicare. Medicare benefits are determined as if the
person were covered under Medicare Parts A and B.
- The person is enrolled in a Medicare Advantage (Medicare Part C) plan and receives
non-covered services because the person did not follow all rules of that plan.
Medicare benefits are determined as if the services were covered under Medicare
Parts A and B.
- The person receives services from a provider who has elected to opt-out of
Medicare. Medicare benefits are determined as if the services were covered under
Medicare Parts A and B and the provider had agreed to limit charges to the amount
of charges allowed under Medicare rules.
- The services are provided in a Veterans Administration facility or other facility of the
federal government. Medicare benefits are determined as if the services were
provided by a non-governmental facility and covered under Medicare.

48 SECTION 9 - COORDINATION OF BENEFITS