Tuesday, October 18, 2016

Concept of Retroactive Eligibility and Spouse and Dependent Coverage

Retroactive Eligibility

If the 1199SEIU Benefit Funds verify a member’s eligibility but subsequently learn that the member was not eligible at the time of service, the member will be retroactively ineligible for services provided and the 1199SEIU Benefit Funds will not be liable for any services rendered
to that ineligible member.

Coordination of Benefits

When a member, spouse or child is covered by more than one group health plan, the two plans share the cost of the member’s family health coverage by “coordinating” benefits.

The primary plan makes the first payment on a claim, and the secondary plan pays an additional amount according to its terms. Members are routinely sent Coordination of Benefits forms in order to establish whether or not the 1199SEIU Benefit Funds are their primary insurance.

If the Benefit Funds are unable to establish if they are the primary or secondary payer, the claim may be denied until additional information is received. Please remind members to complete all requested forms promptly to avoid claim and payment delays.

Spouse and Dependent Coverage

Unless court-ordered, if the member and his or her spouse both have dependent coverage, the primary payer for any children will be the plan of the parent whose birthday is earlier in the year. The other parent’s plan is the secondary payer.

For spousal care, the spouse’s plan is the primary payer. The 1199SEIU Benefit Funds are the member’s primary payer and the spouse’s secondary payer.

Dependent means your spouse or any child covered under the Plan.

Child means a natural child, a stepchild, an adopted child (including a child for whom you or your spouse is a party in a suit in which the adoption of the child is sought), under twenty-six (26) years of age, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, or any combination of those factors. A child of your child must be dependent on you for federal income tax purposes at the time of application of coverage for the child of your child is made under the Plan. A child not listed above whose primary residence is your household and to whom you are legal guardian or related by blood or marriage and who is dependent upon you for more than one-half of his support as defined by the Internal Revenue Code of the United States, is also considered a Dependent child under the Plan.

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