Advocate Health Care
Benefits
Medical Benefits

 


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Non-Duplication of Benefits

If you enroll in an Advocate Medical Plan, 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.

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

You have included your spouse under your coverage with a PPO/DRP medical option.
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 an Advocate PPO/DRP medical option.

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 Benefits Service Center 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.