15.5 HOW MUCH THIS PLAN PAYS WHEN IT IS SECONDARY PAYOR
- When this Plan is secondary, and benefits are eligible expenses under the primary plan and this Plan, the Trust Plan will pay the difference between the Allowable Charges and payments actually made by the primary plan(s). In no event, however, will this Plan pay more than 30% of Allowable Expenses when paying secondary benefits.
- When this Plan is secondary, and benefits are not an eligible expense under the primary plan, but are an eligible expense under this Plan, the Trust Plan will pay benefits as if it were the primary payor in accordance with the standard deductible, co-insurance and plan maximum provisions described in this SPD.
- When this Plan is secondary, and benefits are an eligible expense under the primary plan, but ARE NOT eligible expenses under this Plan, NO TRUST BENEFITS WILL BE PAYABLE. To the extent that payment by this Plan as secondary payor would result in total payments greater than the maximum “usual, customary, and reasonable” allowable fee under this Plan, no benefits will be payable.
“Allowable Expense” means a health care service or expense, including deductibles, coinsurance or copayments, and without reduction for any applicable deductible, that is covered in full or in part by any of the plans covering the Participant, except as provided below or where a statue applicable to this Plan requires a different definition. This means that an expense or service (or any portion of an expense or service) that is not covered by any of the plans is not an Allowable Expense. The following are examples of expenses or services that are not Allowable Expenses:
- The difference between the cost of a semi-private room in a Hospital or other facility and a private room, unless the patient’s stay in a private Hospital room is Medically Necessary.
- If the coordinating plans determine benefits on the basis of usual, customary and/or reasonable charges, any amount in excess of the lowest usual, customary and/or reasonable charge.
- If the coordinating plans provide benefits or services on the basis of negotiated fees, any amount in excess of the lowest of the negotiated fees.
- If one coordinating plan determines benefits on the basis of usual, customary and/or reasonable charges and the other coordinating plan provides benefits or services on the basis of negotiated fees, any amount in excess of the lesser of the two plans’ fees.
- Out-patient prescription drug charges.
- Any expense that a provider by law or in accordance with a contractual agreement is prohibited from charging the Participant.
When benefits are reduced by a primary plan because a Participant did not comply with the primary plan’s provisions, such as provisions related to Utilization Management and/or similar provisions in other plans, the amount of those reductions will not be considered an Allowable Expense of this Plan when it pays second.