Group contracts include “Coordination of Benefits,” which allows an employee to claim under two or more eligible Group benefit plans for up to 100% of a covered expense. If you and your spouse both have benefits, you must submit expenses to the Primary Carrier first. Any remaining costs can be directed to the Secondary Carrier.

The Primary Carrier is the carrier that covers the individual as an employee or member, or as a dependent child of the covered parent whose birthday falls first in the calendar year.

The Secondary Carrier is the carrier that covers the individual as a dependent spouse, or as a dependent child of the covered parent whose birthday falls later in the calendar year.

Should 100% of submitted expenses not be reimbursed by your Primary Carrier, you can submit a claim to the Secondary Carrier, along with the payment notice (Explanation of Benefits/EOB) from the Primary Carrier and copies of all receipts. Make sure to always keep copies of all receipts for this process!

In order to take advantage of Coordination of Benefits, the member and/or spouse and any children must be considered eligible dependents under the other’s Group plan. A member cannot coordinate with their spouse’s plan if they both have elected single coverage.

Benefits such as Basic Life, AD&D, Short Term and Long Term Disability often have a Non Evidence Maximum (NEM) as part of the plan provisions. The NEM is the amount of coverage that an insurer will automatically provide a plan member without requiring medical evidence of good health.

For example, suppose a plan provides Basic Life insurance up to $150,000 with an NEM of $100,000. This means eligibility for the first $100,000 of coverage will not require a health questionnaire, but that the next $50,000 of coverage will be dependent on insurer approval based on evidence of good health.