Dental Blue FT - Other Party Liability

Other Party Liability

 
Coordination of Benefits (COB)

Blue Cross and Blue Shield will coordinate payment of covered dental services with hospital, medical, dental, health or other plans under which you are covered. Blue Cross and Blue Shield will do this to make sure that the cost of your health care services is not paid more than once. Other plans include: personal injury insurance; automobile insurance, including medical payments coverage; homeowner’s insurance; and other plans that cover hospital or medical expenses. You must include information on your enrollment forms about other health plans under which you are covered. Once you are enrolled in Dental Blue Freedom, you must notify Blue Cross and Blue Shield if you add or change health plan coverage. Upon request, you must also supply Blue Cross and Blue Shield with information about other plans that may provide you with coverage for health care services.

Under COB, the plan that provides benefits first is known as the primary payor. And the plan(s) that provide benefits next are known as the secondary payor(s). When coverage under Dental Blue Freedom is secondary, no benefits will be provided until after the primary payor determines its share, if any, of the liability. Blue Cross and Blue Shield decides which is the primary and secondary payor. To do this, Blue Cross and Blue Shield relies on the COB regulations issued by the Massachusetts Division of Insurance (see the COB rules described below). To the extent state law does not govern Dental Blue Freedom, however, state law will not limit Blue Cross and Blue Shield’s discretion to determine which is the primary and secondary payor. For example, Dental Blue Freedom is not subject to Massachusetts requirements concerning coordination between no-fault automobile personal injury protection (PIP) and health insurance, and if PIP is available, Dental Blue Freedom will not pay benefits until PIP is exhausted.

Dental Blue Freedom will not provide any more benefits than those already described in this Dental Blue Freedom Benefit Description. Dental Blue Freedom will not provide duplicate benefits for covered dental services. If Dental Blue Freedom pays more than the amount that it should have under COB, then you must give that amount back to Blue Cross and Blue Shield on behalf of Dental Blue Freedom. Dental Blue Freedom has the right to get that amount back from you or any appropriate person, insurance company or other organization.

Important: If you fail to comply with the provisions of this COB section, payment of your claim may be denied.

COB Rules to Determine the Order of Benefits

When other plan(s) under which you are covered include COB rules consistent with the COB rules described in this section, Blue Cross and Blue Shield will decide which plan is the primary payor and the secondary payor based on these COB rules. However, if another plan under which you are covered does not include COB rules consistent with the COB rules described below, that plan will determine benefits before Dental Blue Freedom.

  • Employee/Dependent Rule. The plan that covers the person who is claiming benefits as an employee (the subscriber) will determine benefits before a plan under which that person is covered as a dependent.
  • Children of Parents Who Are Not Separated or Divorced (“BirthdayRule”). When the person who is claiming benefits is covered under two or more plans as a dependent child of parents who are not separated or divorced, the plan of the parent whose birthday falls earlier in a year will determine benefits before the plan of the parent whose birthday falls later in the year. This is referred to as the “birthday rule.” This refers only to the month and day in a calendar year, not the year in which the parent was born. However, if both parents have the same birthday, the plan that has covered a parent the longest will determine benefits before the plan that has covered a parent for a shorter period of time. (If another plan does not include the “birthday rule” described in this section, but instead includes a rule based on the gender of the parent and as a result, if the plans do not agree on the order of benefits, the “birthday rule” will be used to determine the order of benefits.)
  • Children of Separated or Divorced Parents. When the person who is claiming benefits is a covered child of parents who are separated or divorced, unless there is a court order that requires one parent to be responsible for health care coverage, the order used to determine benefits will be: (1) the plan of the parent who has custody of the child will determine benefits before the plan of the parent who does not have custody of the child; (2) the plan of the spouse of the parent who has custody will determine benefits before the plan of the parent who does not have custody of the child; and then (3) the plan of the parent who does not have custody of the child.
     
    If there is a court decree that states that one of the parents is responsible for health care expenses of the child, the plan covering that parent will determine benefits first, provided that the plan has knowledge of the terms of the court degree. If a court decree grants joint custody but does not state that one parent is responsible for the child’s health care expenses, the “birthday rule” described above will be used to determine the order of benefits.
  • Active/Inactive Employee Status. The plan that covers the person who is claiming benefits as an active employee (or as a dependent of that employee) will determine benefits before a plan under which that person is covered as a laid-off or retired employee (or as a dependent of that employee). If another plan does not include this COB rule and if, as a result the plans do not agree on the order of benefits, this COB rule will not be used to determine the order of benefits.
  • Plans With the Earlier Effective Date. If none of the previous COB rules determine the order of benefits, the plan that has covered the person who is claiming benefits longer will be determined before the plan that has covered the person who is claiming benefits for a shorter period of time.

Note: If other plan(s) under which you are covered do not include COB rules consistent with the COB rules described in this section, that plan will determine benefits before Dental Blue Freedom.

Medicare Program

When you are eligible for the Medicare program and Medicare is allowed by federal law to be the primary payor, the benefits provided by Dental Blue Freedom will be reduced by the amount of benefits allowed under Medicare for the same covered dental services. This reduction will be made whether or not you actually receive the benefits from Medicare.

Plan Rights to Recover Benefit Payments

Subrogation and Reimbursement of Benefit Payments
If you are injured by any act or omission of another person, the benefits under Dental Blue Freedom will be subrogated. This means that Dental Blue Freedom and Blue Cross and Blue Shield, as Dental Blue Freedom’s representative, may use your right to recover money from the person(s) who caused the injury or from any insurance company or other party. If you recover money, Dental Blue Freedom is entitled to recover up to the amount of the benefit payments that it has made. This is true no matter where or by whom the recovered money is held or how it is designated and even if you do not recover the total amount of your claim against the other person(s). This is also true if the payment you receive is described as payment for other than health care expenses. The amount you must reimburse Dental Blue Freedom will not be reduced by any attorney’s fees or expenses you incur.

Member Cooperation
You must give Blue Cross and Blue Shield, as Dental Blue Freedom’s representative, information and help. This means you must complete and sign all necessary documents to help Blue Cross and Blue Shield get this money back on behalf of Dental Blue Freedom. This also means that you must give Blue Cross and Blue Shield timely notice of all significant steps during the negotiation, litigation or settlement with any third party (such as filing a claim or lawsuit, initiation of settlement discussions, agreement to a settlement in principle, etc.) and before settling any claim arising out of injuries you sustained by an act or omission of another person(s) for which Dental Blue Freedom paid benefits. You must not do anything that might limit Dental Blue Freedom’s right to full reimbursement.

Workers’ Compensation
No benefits are provided for health care services that are furnished to treat an illness or injury that Blue Cross and Blue Shield determines was work related. This is the case even if you have an agreement with the workers’ compensation carrier that releases them from paying for the claims. All employers provide their employees with workers’ compensation or similar insurance. This is done to protect employees in case of a work-related illness or injury. All health care claims for a work-related illness or injury must be billed to the employer’s workers’ compensation carrier. It is up to you to use the workers’ compensation insurance. If Dental Blue Freedom pays for any work-related health care services, Blue Cross and Blue Shield on behalf of Dental Blue Freedom has the right to get paid back from the party that legally must pay for the health care claims. Blue Cross and Blue Shield also has the right on behalf of Dental Blue Freedom, where possible, to reverse payments made to providers.

If you have recovered any benefits from a workers’ compensation insurer (or from an employer liability plan), Blue Cross and Blue Shield has the right on behalf of Dental Blue Freedom to recover from you the amount of benefits it has paid for your health care services. This is the case even if:

  • the workers’ compensation benefits are in dispute or are made by means of a settlement or compromise;
  • the workers’ compensation benefits are in dispute or are made by means of a settlement or compromise;
  • the amount of workers’ compensation due to medical or health care is not agreed upon or defined by you or the workers’ compensation carrier; or
  • the medical or health care benefits are specifically excluded from the workers’ compensation settlement or compromise.

If Blue Cross and Blue Shield is billed in error for these services, you must promptly call or write Blue Cross and Blue Shield’s customer service office.