Advocate Health Care
Benefits
Medical

 
Resources    Forms   

Dental HMO    Dental HMO Copayment Schedule    MetLife PDP    MetLife Dental ID CARD    Rates   
Disability Certification    Disability Council    Eligibility Requirements    Long Term Disability Plan    Restricted Duty    Short Term Disability Plan    Social Security Disability Benefits   Vocational Rehabilitation Services   
Dependent Coverage    Eligibility    Enrollment Process    Estimated Imputed Income Chart    Paying for Benefits   
Account Rules    Eligible Dependent Day Care Expenses    Eligible Health Care Expenses    Reimbursement Process    Tax Advantages   
ActiveHealth®    Healthe Actions    Healthe Eating    Healthe Breathing    Healthe Care    HealthMedia    Healthe TRENDS    Know Your Numbers    Questions & Answers   
FAQs  
Special Features    Beneficiaries    Optional AD&D Insurance    Optional Life Insurance   
HDHP   HMO   HMO Physician Search   HSA   Medicare Part D   Non-Duplication of Benefits   PPO   PPO/HDHP Covered Services   PPO Physician Search   Rates   Woman's Health and Cancer Rights Act of 1998  
PTO Sharing/Donation  
Auto and Homeowners' Insurance    Long Term Care Insurance    Universal Life Insurance   
Retirement Savings Plan    Portable Pension Plan   
Primary Benefits   Secondary Benefits   Rates  

   expand  |  collapse

   
 
Non-Duplication of Benefits

If you choose the CoreSource PPO, HumanaPPO or HumanaHMO coverage option, include a family member under your coverage and this family member also has coverage under another plan, your Advocate coverage may provide primary or secondary coverage for this family member under the “non-duplication of benefits” provision.

Important! If you have HMO coverage as either your primary or secondary coverage, you must follow that HMO’s requirements in order to receive any benefits from that plan. Because you cannot have any other medical coverage if you choose the High-Deductible Health Plan (HDHP), this coordination of benefits provision will not apply to you if choose the HDHP coverage option.

To see how this non-duplication of benefits provision works, let’s assume that:

You have included your spouse under your coverage with one of Advocate’s PPO medical options.
Your spouse also is covered by his or her employer-sponsored medical plan.
Your spouse undergoes inpatient surgery performed by participating providers.
Your spouse already has met the deductible under both plans, and both plans provide 80% of the cost of covered services.

Your spouse’s coverage under his or her employer-sponsored plan will be primary, so that plan will pay benefits first. Since both plans provide 80% of covered charges, the full benefit your spouse receives will be paid by his or her employer-sponsored coverage and no benefits will be paid under the Advocate PPO.

Here are some guidelines for determining whether a plan is primary or secondary:
A plan is “primary” if you are the employee and it is your employer’s plan.
If you cover your spouse as a dependent under your Advocate coverage and your spouse also has medical coverage through his or her employer, your spouse’s plan will be his or her primary plan, and your Advocate coverage will be secondary.
If you cover your eligible children as dependents under Advocate coverage and your spouse also covers them as dependents under his or her employer plan, determination of which plan is primary will be based on the “birthday rule.” Under this rule, the coverage of the parent who has the birthday month that falls earlier in the year (e.g., March vs. August) will be the primary health plan for all dependent children.
If you are working and covered by medicare, the Advocate medical plan will be primary and medicare will be the secondary plan.

Refer to the Plan Summary of your elected Advocate medical plan for more detailed information.

Important! Each year, Advocate InfoExpress or its benefit administrators will ask you to update information regarding the health coverage that you and your covered dependents have, including any coverage that you may have in addition to the Advocate plans. You will need to respond to the request by the deadline given; otherwise, claims will be pended. Any claims that you file for benefits from the plans after that date will be paid only if you have responded to the request. No further benefits will be paid until your response is received.