Spousal Coordination of Benefits Policy


This health insurance plan policy became effective with the State of Delaware on January 1, 1993 and is applicable to you if you cover your spouse under the plan and s/he is eligible for health care coverage through his or her own employer. In order to certify that your spouse is or is not covered by a plan where s/he works, you MUST complete a Spousal Coordination of Benefits Policy Form if you are enrolled in the University’s health insurance plan for employee and spouse or family coverage. 
 
IF YOU ARE COVERING, OR PLAN TO COVER, YOUR SPOUSE UNDER THE UNIVERSITY’S HEALTH INSURANCE PLAN, IT IS YOUR RESPONSIBILITY TO UPDATE YOUR SPOUSAL INFORMATION WITHIN 30 DAYS AFTER YOUR SPOUSE LOSES OR GAINS HEALTH INSURANCE COVERAGE WITH HIS OR HER EMPLOYER.
 
The following section describes how this policy effects payment of health insurance benefits for spouses who are employed.
 
How payment of Benefits for Spouses is Affected
The following describes how the policy effects the benefits payment for spouses:

  • If your spouse is eligible for and not enrolled in the health care plan offered by his or her own employer, the State will pay 20% of allowable charges for services covered under the State's health care plan.
  • If your spouse is eligible for and enrolled in the health care plan offered by his or her own employer, the State will pay for benefits provided under the State's health care plan after your spouse's health care plan pays. Payment from both plans combined will not exceed 100% of covered charges.
  • If your spouse is not eligible for and, therefore, is not enrolled in the health care plan where he or she works or any other health care plan, the State will pay for benefits as provided under the your selected State health care plan.


How to Determine When Your Spouse Should be Enrolled in His or Her Employer's Health Insurance Plan
Generally, your spouse does not need to be enrolled in the health care plan where he or she works if ONE of the following reasons applies:

  • Your spouse does not work full-time; or
  • Your spouse is not eligible for benefits under his or her employer's health care plan because s/he has not satisfied his or her employer's requirements as to the number of hours worked; or
  • Your spouse's medical history does not meet the underwriting requirements of his or her employer's health care plan; or
  • Your spouse's employer requires a contribution of more than 50% of the premium for the lowest benefit plan available (all flexible benefit dollars and/or credits available to your spouse are counted as contributions provided by your spouse's employer); or
  • Your spouse's employer does not offer medical coverage.


Examples to Determine Enrollment in Spouse's Employer's Plan
The following chart illustrates examples that will help you determine when your spouse should be enrolled in his or her employer’s health insurance plan. In these examples, it is assumed that there is health care coverage offered through the spouse’s employer.

Situation Spouse Should Obtain Coverage Through His or Her Employer Not Necessary For Spouse to Be Covered By His or Her Employer
Spouse is employed full-time and is eligible for coverage. X  
Spouse is in active military duty. X  
Spouse is self-employed and, as sole proprietor, he or she would have to contribute 100% of health care cost.   X
Spouse is a partner, owner or part owner of a company or corporation and full-time employees are required to contribute 50% or less of health care costs. X  
Spouse is a partner, owner or part owner of a company or corporation and full-time employees are required to contribute more than 50% of health care costs.   X
Spouse is retired from an employer other than the State, does not have retiree health care coverage, and employed full-time with another employer who offers coverage for which the spouse must contribute 50% or less. X  
Spouse is retired from an employer other than the State, does not have retiree health care coverage, and is employed full-time with another employer who offers coverage for which the spouse must contribute more than 50%.   X
Spouse is retired from an employer (including the State), and the spouse is covered under the retiree health care coverage, and is employed full-time with another employer.   X
Spouse applies for coverage through employer and is denied coverage due to poor health.   X
Spouse applies for coverage through his/her employer, is approved, but there is a pre-existing condition waiting period. (See applicable section below). X  
Spouse’s employer offers only an HMO program and the spouse does not reside in the HMO program services area. (See applicable section below).   X


How to Determine if Your Spouse Works Full-time
Based on the State's rule regarding full-time status, Full-time means that an individual works 30 or more hours per week.  However, if your spouse works less than the full-time hours as required by his or her employer and therefore receives less than the full-time contribution towards health care coverage, then your spouse is considered part-time even though s/he works more than the 30 hours per week. Under these circumstances, the spouse is not required to obtain coverage through his or her employer.
 
For example:
Your spouse works for an employer that contributes $200 toward the cost of health care coverage for each full-time employee and requires a 40 hour work week in order for the employee to be considered full-time.  Because your spouse works only 32 hours per week, his/her employer contributes $160 towards his or her health care plan contribution. Since the spouse works less than the required number of hours and receives less than the full-time contribution, the spouse is considered part-time under the State’s eligibility guidelines.
 
How to Determine the 50% Contribution Requirement
When determining contributions made by your spouse's employer to his or her health care plan, all flexible benefit dollars and/or credits available to your spouse are counted as contributions provided by your spouse's employer.  If these contributions are less than 50% of the premium for the lowest benefit plan available through your spouse's employer, it is not necessary for your spouse to enroll in his or her employer's plan.
 
What Happens When There is a Preexisting Condition Waiting Period
Your spouse's employer's plan may have an eligibility waiting period (a time period when your spouse is not eligible to enroll for benefits) or a contribution waiting period (a time period when your spouse is responsible for the cost of the health care plan). In either case, benefits may be provided under your selected State health care plan until the waiting period has been satisfied.  Once your spouse has satisfied the eligibility and/or contribution waiting period, all benefits will be paid according to the Coordination of Benefits section, unless your spouse fails to enroll under his or her employer's plan when he or she is eligible. If your spouse fails to enroll under his or her employer's plans, then benefits will be paid at 20% of the allowable charge as specified in the section, Payment of Benefits for Spouses.
 
What Happens When the Spouse's Employer Only Offers an HMO PROGRAM?
Some employers may only offer an HMO program but your spouse lives outside of the HMO program service area.  In such instances, it is not necessary that your spouse enroll under his or her employer's plan. However, the State will evaluate your spouse's enrollment under his or her employer's plan on an annual basis.  If, in the judgment of the State, your spouse's employer is offering an HMO program only to avoid covering spouses of State employees, then the State reserves the right to pay benefits at 20% of the allowable charge for services covered under the Employee's selected State health care plan.
 
NOTE:
Benefits for dependent children are paid according to the provisions described in Coordination of Benefits when dependent children are covered under one of the State's health care plan as well as another health care plan.