Which Plan Pays Benefits First
If your other plan does not coordinate benefits, it is
automatically considered the primary plan for coverage,
and it is required to pay benefits first. If both plans
coordinate benefits, these guidelines apply:
- The health plan covering the patient directly is the
primary plan and pays first, and the other plan is
secondary. For example, coverage under this Plan is
primary for you but secondary for your spouse if he or
she has coverage through his or her employer. If both
the husband and the wife are covered in MILA, the
husband’s Plan is primary for him and secondary for
his wife and the wife’s coverage is primary for her and
secondary for her husband;
- If a dependent child lives with both parents and the
child is covered by both parents’ plans, the plan of the
parent whose birthday falls earlier in the calendar year
pays benefits first for that child. If both parents have
the same birthday, the plan that has covered one of
the parents longer pays first. If one parent’s plan does
not recognize these “birthday” coordination rules, the
father’s plan pays first;
- In a case of divorce or separation, the plan of the
parent who has court-ordered financial responsibility
for the dependent child pays first. If there is no court
order, the plan of the parent with actual custody,
whether or not he or she remarries, pays first. For
court-ordered joint custody, the birthday rules
described above apply;
- If a court decree gives financial responsibility of a dependent child to one parent, then that parent’s plan pays first;
- If none of the preceding rules apply:
- The primary plan is the one covering the patient for the longest period of time, and pays first; or
- The health plan covering an individual because of active employment pays before any plan covering the person as a pensioner or as a participant under COBRA continuation coverage.
