Coordination of Benefits (COB)

Some individuals have vision care coverage in addition to this plan. For example, you may be covered as a dependent under your spouse's vision care plan.

The City's Vision Plan works with other group plans to reimburse up to 100% of the allowable expenses for you and your dependents. An allowable expense is any expense covered at least in part by this plan. The maximum amount payable by the plan is limited to the amount that would have been paid if there were no other plans involved.

How COB Works

Here's how benefits are coordinated when a claim is made:

the primary plan pays benefits first without regard to any other plan; and

the secondary plan adjusts its payments so that the total benefit paid will not be greater than your allowable expense.

A plan without a coordinating provision is always the primary plan. If all plans have a coordinating provision, here's how benefit payments will be determined:

The plan covering the patient directly, rather than as a dependent, will be the primary plan.

If a child is covered under both parents' plans, the plan covering the parent whose birthday comes first in a calendar year is the primary plan. If both parents have
the same birthday, the plan of the parent who has been covered longer is the primary plan. If the other plan does not have this rule but has a rule based on the gender of the parent, then the rule of the other plan will determine the order of benefits.

If you are legally separated or divorced, the order will be as follows:

- if the court has established one parent as financially responsible for the child's health care, the plan of the parent with that responsibility is primary; then

- the plan of the parent with custody of the child; then

- the plan of the step-parent married to the parent with custody of the child; then

- the plan of the parent that does not have custody of
the child.

The City's plan will pay the benefits explained in this section of the handbook when this plan is the primary plan. When this plan is the secondary or later plan, it will usually pay the difference between benefits paid from the primary plan and the benefits provided by this plan. However, the total benefits paid will not be more than what would have been paid if this plan were primary.

November 2002 Continue