This section applies if you or any one of your Family Members is covered under more than one group health plan and determines how benefits payable from all such group health plans will be coordinated. You should file all claims with each group health plan.
For the purposes of this section, the following terms have the meanings set forth below:
Group health plan
Any of the following that provides benefits or services for medical, dental, or vision care or treatment:
- Group insurance and/or group-type coverage, whether insured or uninsured. This includes prepayment, group practice or individual practice coverage.
- Coverage under Medicare and other governmental benefits as permitted by law accepting Medicaid and Medicare supplement policies. It does not include any plan when benefits are in excess to those of any private insurance program or other non-governmental program.
- Medical benefits coverage of group, group-type, and individual "no-fault" and traditional automobile "fault" contracts.
Each Group Health Plan or part of a Group Health Plan which has the right to coordinate benefits will be considered a separate Group Health Plan.
Closed panel group health plan
A Group Health Plan that provides medical or dental benefits primarily in the form of services through a panel of employed or contracted providers, and that limits or excludes benefits provided by providers outside of the panel, except in the case of emergency or if referred by a provider within the panel.
Primary group health plan
The Group Health Plan that determines and provides or pays benefits without taking into consideration the existence of any other Group Health Plan.
Secondary group health plan
A Group Health Plan that determines, and may reduce its benefits after taking into consideration, the benefits provided or paid by the Primary Group Health Plan. A Secondary Group Health Plan may also recover from the Primary Group Health Plan the Reasonable Cash Value of any services it provided to you.
A necessary, reasonable and customary service or expense, including deductibles, coinsurance or co-payments, that is covered in full or in part by any Group Health Plan covering you. When a Group Health Plan provides benefits in the form of services, the Reasonable Cash Value of each service is the Allowable Expense and is a paid benefit.
Prior Mental Health/Substance Abuse Treatment
Examples of expenses or services that are not Allowable Expenses include, but are not limited to the following:
- An expense or service or a portion of an expense or service that is not covered by any of the Plans is not an Allowable Expense.
- If you are confined to a private Hospital room and no Group Health Plan provides coverage for more than a semiprivate room, the difference in cost between a private and semiprivate room is not an Allowable Expense.
- If you are covered by two or more Group Health Plans that provide services or supplies on the basis of reasonable and customary fees, any amount in excess of the highest reasonable and customary fee is not an Allowable Expense.
- If you are covered by one Group Health Plan that provides services or supplies on the basis of reasonable and customary fees and one Group Health Plan that provides services and supplies on the basis of negotiated fees, the Primary Group Health Plan’s fee arrangement shall be the Allowable Expense.
- If your benefits are reduced under the Primary Group Health Plan (through the imposition of a higher co-payment amount, higher coinsurance percentage, a deductible and/or a penalty) because you did not comply with Group Health Plan provisions or because you did not use a preferred provider, the amount of the reduction is not an Allowable Expense. Such Group Health Plan provisions include second surgical opinions and pre-certification of admissions or services.
Claim determination period
A calendar year, but does not include any part of a year during which you are not covered under this Cigna OAPIN Option or any date before this section or any similar provision takes effect.
Reasonable cash value
An amount which a duly licensed provider of health care services usually charges patients and which is within the range of fees usually charged for the same service by other health care providers located within the immediate geographic area where the health care service is rendered under similar or comparable circumstances.
Order of benefit determination rules
A Group Health Plan that does not have a coordination of benefits rule consistent with this section shall always be the Primary Group Health Plan. If the Group Health Plan does have a coordination of benefits rule consistent with this section, the first of the following rules that applies to the situation is the one to use:
- The Group Health Plan that covers you as an enrollee or a retiree shall be the Primary Group Health Plan and the Group Health Plan that covers you as a Eligible Family Member shall be the Secondary Group Health Plan;
- If you are a child whose parents are not divorced or legally separated, the Primary Group Health Plan shall be the Group Health Plan which covers the parent whose birthday falls first in the calendar year as an enrollee or retiree;
- If you are the child of divorced or separated parents, benefits for the Eligible Family Member shall be determined in the following order:
- first, if a court decree states that one parent is responsible for the child's healthcare expenses or health coverage and the Group Health Plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge;
- then, the Group Health Plan of the parent with custody of the child;
- then, the Group Health Plan of the spouse of the parent with custody of the child;
- then, the Group Health Plan of the parent not having custody of the child, and
- finally, the Group Health Plan of the spouse of the parent not having custody of the child.
- The Group Health Plan that covers you as an active employee (or as that employee's Family Member) shall be the Primary Group Health Plan and the Group Health Plan that covers you as laid-off or retired employee (or as that employee's Family Member) shall be the secondary Group Health Plan. If the other Group Health Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply.
- The Group Health Plan that covers you under a right of continuation which is provided by federal or state law shall be the Secondary Group Health Plan and the Group Health Plan that covers you as an active employee or retiree (or as that employee's Eligible Family Member) shall be the Primary Group Health Plan If the other Group Health Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply.
- If one of the Plans that covers you is issued out of the state whose laws govern this Policy, and determines the order of benefits based upon the gender of a parent, and as a result, the Plans do not agree on the order of benefit determination, the Group Health Plan with the gender rules shall determine the order of benefits.
If none of the above rules determines the order of benefits, the Group Health Plan that has covered you for the longer period of time shall be primary.
When coordinating benefits with Medicare, this Cigna OAPIN Option will be the Secondary Group Health Plan and determine benefits after Medicare, where permitted by the Social Security Act of 1965, as amended. However, when more than one Group Health Plan is secondary to Medicare, the benefit determination rules identified above will be used to determine how benefits will be coordinated.
Effect on the benefits of this Cigna OAPIN option
If this Cigna OAPIN Option is the Secondary Group Health Plan, this Group Health Plan may reduce benefits so that the total benefits paid by all Plans during a Claim Determination Period are not more than one hundred percent (100%) of the total of all Allowable Expenses.
The difference between the amount that this Cigna OAPIN Option would have paid if this Cigna OAPIN Option had been the Primary Group Health Plan, and the benefit payments that this Cigna OAPIN Option had actually paid as the Secondary Group Health Plan, will be recorded as a benefit reserve for you. Cigna will use this benefit reserve to pay any Allowable Expense not otherwise paid during the Claim Determination Period.
As each claim is submitted, Cigna will determine the following:
- Cigna obligation to provide services and supplies under this Cigna OAPIN Option ;
- Whether a benefit reserve has been recorded for you; and
- Whether there are any unpaid Allowable Expenses during the Claims Determination Period.
If there is a benefit reserve, Cigna will use the benefit reserve recorded for you to pay up to one hundred percent (100%) of the total of all Allowable Expenses. At the end of the Claim Determination Period, your benefit reserve will return to zero (0) and a new benefit reserve shall be calculated for each new Claim Determination Period.
Recovery of excess benefits
If Cigna pays charges for benefits that should have been paid by the Primary Group Health Plan, or if Cigna pays charges in excess of those for which we are obligated to provide under the plan, Cigna will have the right to recover the actual payment made or the Reasonable Cash Value of any services.
Cigna will have sole discretion to seek such recovery from any person to, or for whom, or with respect to whom, such services were provided or such payments made by any insurance company, healthcare plan or other organization. If we request, you shall execute and deliver to us such instruments and documents as we determine are necessary to secure the right of recovery.
Right to receive and release information
Cigna, without consent or notice to you, may obtain information from and release information to any other Group Health Plan with respect to you in order to coordinate your benefits pursuant to this section. You must provide us with any information we request in order to coordinate your benefits pursuant to this section. This request may occur in connection with a submitted claim; if so, you will be advised that the "other coverage" information, (including an Explanation of Benefits paid under the Primary Group Health Plan) is required before the claim will be processed for payment. If no response is received within 90 days of the request, the claim will be denied. If the requested information is subsequently received, the claim will be processed.
Right of reimbursement
The Cigna OAPIN Option does not cover:
- Expenses for which another party may be responsible as a result of liability for causing or contributing to the injury or illness of you or your Family Member(s).
- Expenses to the extent they are covered under the terms of any automobile medical, automobile no fault, uninsured or underinsured motorist, workers' compensation, government insurance, other than Medicaid, or similar type of insurance or coverage when insurance coverage provides benefits on behalf of you or your Family Member(s).
If you or a Family Member incurs health care Expenses as described above, Cigna shall automatically have a lien upon the proceeds of any recovery by you or your Family Member(s) from such party to the extent of any benefits provided to you or your Family Member(s) by the Plan. You or your Family Member(s) or their representative shall execute such documents as may be required to secure Cigna’s rights. Cigna shall be reimbursed the lesser of:
- The amount actually paid by Cigna under the Plan; or
- An amount actually received from the third party;
- At the time that the third party's liability is determined and satisfied; whether by settlement, judgment, arbitration or otherwise.