UpDate - Vol. 11, No. 31, Page 8
May 14, 1992
Coordination needed for spousal benefits provision
The new spousal coordination of benefits provision applies if
your spouse works full-time and is eligible for coverage through
his/her employer. This provision does not apply if your spouse is not
working full-time, his/her employer does not offer medical coverage,
or his/her employer requires a contribution of more than 50% of the
premium for the lowest health care plan available. Spouses who work
for the University of Delaware and eligible dependent children are
also excluded.
Q. When does the new coordination of benefits for spouses go into
effect?
A. This new provision takes effect January 1, 1993. You will be
able to drop your spouse from your health care coverage in
December for January as the State has determined that this
qualifies as a life event.
Q. What if my spouse's employer does not have an open enrollment
between now and January 1, 1993?
A. An exception will be made until the spouse can enroll in
his/her employer's plan, but in no event will the exception
extend beyond May 1, 1993.
Q. What is the definition of part-time under the new spousal
coordination of benefits policy?
A. If the spouse can show that he/she works less than the full
time hours of his/her employer (i.e., spouse works 32 hours when
other employees work 40) and is credited with less than the full
time employer contribution towards health insurance (i.e., the
40-hour employee receives a $200 employer contribution but the
32-hour employee receives a $160 employer contribution) then
he/she will be considered part-time; the new coordination of
benefits provision will not apply.
Q. What if the spouse is on active military status?
A. If the spouse is an active member of the military, the new
coordination of benefits provision will apply; the spouse will be
expected to use the military benefits available.
Q. My spouse works for one of the school districts, does he/she have
to take coverage through the school district?
A. No, spouses who work for the state of Delaware, the school
districts, Delaware Technical and Community College, Delaware
State College, or any of the state agencies are exempt from the
spousal coordination of benefits provision as they are members of
the state group.
Q. How does the coordination of benefits affect spouses who are
self-employed?
A. If a spouse is self-employed, the company is a sole
proprietorship, and the company offers a group health insurance
plan to its employees, the spouse will be considered as paying
100 percent of the coverage (as the sole proprietor) and the new
coordination of benefits provision will not apply.
If the spouse is a partner in a company that offers a group
health insurance plan to its employees, the new coordination of
benefits provision will apply unless it can be shown that the
company requires all of its other employees to contribute more
than 50 percent of the cost of the health insurance coverage.
If the spouse is an owner or part-owner of a corporation that
offers a group health insurance plan to its employees, the new
coordination of benefits provision will apply, unless it can be
shown that the company requires all of its other employees to
contribute more than 50 percent of the cost of the health
insurance coverage.
Q. What about spouses who have retired?
A. If a spouse is retired and not actively employed full-time,
the new coordination of benefits provision will not apply.
If the spouse is retired from the private sector, a public
employer, or the military and is actively employed with another
employer who offers a group health insurance plan to its
employees, the new coordination of benefits provision will apply.
If the spouse is retired from the private sector, a public
employer, or the military and is actively employed with another
employer who offers a group health insurance plan to its
employees, but has health insurance coverage from the employer
he/she retired from, the new coordination of benefits provision
will not apply.
Q. How will pre-existing conditions situations be handled?
A. If a spouse applies for coverage with his/her employer and is
denied coverage as a result of poor health, the new coordination
of benefits provision will not apply if the spouse provides
documentation that application was made and coverage was denied
as an unacceptable risk.
If a spouse applies for coverage with his/her employer and is
approved but has a waiting period for coverage for a pre-existing
condition, the new coordination of benefits provision will apply
to all other claims. Once the waiting period has been satisfied,
the new coordination of benefits provision will also apply to the
pre-existing condition.
Q. How will the coordination of benefits provision work with managed
care programs?
A. HMO (COPAY)
When the spouse has an office visit at the HMO, he/she should
give HMO the information to bill the spouse's insurance coverage.
The spouse will be charged the $5 copay for the visit. The
balance for the office visit will be forwarded to the spouse's
insurance. If the balance is paid either partially or in full,
the $5 will be credited to his/her account at HMO. If no payment
is received, the spouse will not be billed for the remaining
cost. This same procedure will be used for prescriptions.
Laboratory and radiology charges will be billed directly to the
spouse's insurance.
Spouses of HMO members should make every effort to follow the
guidelines of their employer's coverage.
TOTAL HEALTH PLUS
The Total Health Plus physician has the option of accepting the
$5 copay for an office visit and billing the spouse's insurance
for the balance or requiring the cost of the visit to be paid in
full. If payment in full is required, the spouse must submit the
charges to his/her insurance company and then forward the
explanation of benefits, a copy of the charges, a short note
explaining why this claim is being sent and a copy of the Total
Health Plus card to: Total Health Plus, P.O. Box 8784,
Wilmington, DE 19899. The subscriber will be reimbursed for the
cost of the visit minus the copay amount.
Prescriptions will be handled in a similar manner. Although
pharmacies will have the option of accepting the copayment, most
will probably require payment in full. The same reimbursement
procedure described for office visits must be followed for
prescription reimbursements.
Laboratory and radiology charges will be billed directly to the
spouse's insurance.
Spouses of Total Health Plus members should make every effort to
follow the guidelines of their employer's coverage.
PRINCIPAL HEALTH CARE
The Principal Health Care physician has the option of accepting
the $5 copay for an office visit and billing the spouse's
insurance for the balance or requiring the cost of the visit to
be paid in full. If payment in full is required, the spouse must
submit the charges to his/her insurance company and then forward
the explanation of benefits, a copy of the charges, a short note
explaining why this claim is being sent and a copy of the
Principal Health Care card to: Principal Health Care, 100 West
Commons Boulevard, Suite 300, New Castle, DE, 19720. The
subscriber will be reimbursed for the full cost of the visit.
Prescriptions will be handled in a similar manner. Although
pharmacies will have the option of accepting the copayment, most
will probably require payment in full. The same reimbursement
procedure described for office visits must be followed for
prescription reimbursements.
Laboratory and radiology charges will be billed directly to the
spouse's insurance.
Spouses of Principal Health Care members need to remember that
they must follow the guidelines of their employer's coverage
first for Principal Health Care to coordinate benefits.