UpDate - Vol. 12, No. 29, Page BENEFITS-2
April 29, 1993
Benefits
About coordination of benefits

Q. Who has coordination of benefits?
A. You have coordination of benefits if you have more than one insurer
     providing benefits for:
        - You (the employee) and/or
        - Your spouse and/or
        - Your dependents

Q. What does coordination of benefits do for you?
A. Coordinating benefits ensures that you receive the maximum amount of
     benefits to which you are entitled. You (and/or your dependents) can
     receive maximum benefits when you follow all program guidelines,
     including managed care requirements. When you are covered by two
     plans, it's especially important for you to know your
     responsibilities. If you do not follow both plans' guidelines, you may
     receive zero or reduced benefits.

Q. How do primary and secondary plans pay?
A. If you are a University employee and take coverage through the state
     of Delaware group program, your University coverage is primary for
     you. This means the University plan pays first for your covered
     medical services.
 
     Any reimbursement for covered services depends on the allowable
     payment for the benefit and, more importantly, whether or not you
     followed your plan guidelines for the particular benefit. Your
     University plan will pay up to benefit maximums if you satisfy the
     plan's guidelines.
 
     Any other plan (such as your spouse's plan) which lists you as a
     dependent is secondary for you. Secondary plans pick up any additional
     balance for covered medical services, paying up to benefit maximums
     for that plan. An added feature is that if you exceed benefit maximums
     under your primary plan-- by exhausting dollar amounts, visits, or
     time limitations-- and you have the same services available in your
     secondary plan, the secondary plan provides benefits anew up to its
     benefit maximums.
 
     The University plan may either be primary or secondary for your
     eligible dependents. According to the state's Spousal Coordination of
     Benefits Policy initiated last year, eligible children and spouses may
     remain on your contract as dependents.

     For children?
 
     When children are listed as dependents on two plans, the birthday rule
     determines which plan is primary and which is secondary for your
     children. If your birthday falls first in the calendar year, your plan
     is primary for eligible children. If your spouses's birthday is first,
     your spouse's plan is primary.

     For spouses?
 
     Spouses who are ineligible for other medical coverage can be covered
     through the University. If a spouse has other coverage through his or
     her employer, the spouse's plan pays first and the University plan
     pays second. Both primary and secondary plans will pay up to benefit
     maximums for eligible dependents when dependents satisfy all plan
     guidelines.