Virginia Administrative Code › Title 1 - ADMINISTRATION › Agency 55 - DEPARTMENT OF HUMAN RESOURCE MANAGEMENT › Chapter 20 - COMMONWEALTH OF VIRGINIA HEALTH BENEFITS PROGRAM › Part IV - Employee Participation › Section 1VAC55-20-430 - Coordination of benefits

Current through Register Vol. 40, No. 24, July 15, 2024
A. Employees
				  are required to notify the plan administrator that they or a covered dependent
				  are enrolled under another plan. If a plan participant is eligible for coverage
				  under two or more plans, the plans involved will share the responsibility for
				  the participant's benefits according to these rules.
B. If the other health benefit plan contains
				  a coordination of benefits provision establishing the substantially same order
				  of benefit determination rules as the ones in this section, the following will
				  apply in the order of priority listed:
1. The
				  plan that lists the person receiving services as the enrollee, insured or
				  policyholder, not as a dependent, will provide primary coverage. There is one
				  exception. If the person is also entitled to Medicare, and as a result of
				  federal law Medicare is (i) secondary to the plan covering the person as a
				  dependent; and (ii) primary to the plan covering the person as other than a
				  dependent (e.g., a retired employee), then the benefits of the plan covering
				  the person as a dependent are determined before those of the plan covering the
				  person as other than a dependent.
2. Primary coverage for an enrolled child
				  will be the plan which lists the parent whose month and day of birth occurs
				  earliest in the calendar year as an enrollee, insured, or policyholder, except
				  in the following circumstances:
a. When the
				  parents are separated or divorced, primary coverage will be the plan that
				  covers the child as a dependent of the parent with custody. The plan of the
				  husband or wife of a remarried parent with custody may provide primary coverage
				  if the remarried parent with custody does not have a plan that covers the
				  child.
b. Despite subdivision 2 a
				  of this subsection, if there is a court order that requires one parent to
				  provide hospital or medical/surgical coverage for the child, primary coverage
				  will be that parent's plan. If the specific terms of a court decree state that
				  the parents will share joint custody and the court decree does not state that
				  one of the parents is responsible for health care expenses of the child, then
				  the rule set forth in the first sentence of subdivision 2 of this subsection,
				  the birthday rule, will apply.
3. If subdivisions 1 and 2 of this subsection
				  do not apply, primary coverage will be the plan that has covered the
				  participant for the longest uninterrupted period of time. There are two
				  exceptions to this rule:
a. The benefits of
				  the plan that covers the person as a working employee (or the employee's
				  dependent) will be determined before those of the plan that covers the person
				  as a laid-off or retired employee (or the employee's dependent).
b. The benefits of the plan that covers the
				  person as an employee (or the employee's dependent) will be determined before
				  those of the plan that covers the person under a right of continuation pursuant
				  to federal or state law.