ISSAIC The Information Source for SAIC
SAIC Benefits Summary Plan Description Health & Welfare Benefits for You and Your Family

Coordination of Benefits

If a participant or a participant's dependents are covered under another dental plan, then that plan and the SAIC Dental PPO Plan will work together to pay up to 100% of the charges or the normal level of benefits, whichever is less.

When the SAIC Dental PPO Plan is the primary plan, benefits are paid without regard to any other plans. The participant is responsible for coordinating any benefits by submitting the Explanation of Benefits and itemized bill to the secondary plan.

Determining Which Plan Pays First

SAIC uses the following insurance industry guidelines for determining the primary and secondary payers for employees and dependents.

Employees

The plan that covers the participant as an employee is the primary payer. The plan that covers the participant as a dependent is the secondary payer.

Dependents

For an employee's spouse or registered domestic partner, a plan that covers the spouse or registered domestic partner as an employee is the primary payer for his or her claims. If an employee has elected coverage for his or her spouse or registered domestic partner as a dependent and the spouse or registered domestic partner has coverage through another employer, the SAIC Dental PPO Plan is the secondary payer.

For an employee's dependent children, the plan of the parent whose birthday occurs first in the calendar year is usually the primary payer. If an employee's spouse's or registered domestic partner's plan does not follow this "birthday rule," then the "gender rule" applies. That is, the plan covering the child's father as an employee pays first.

In the case of divorced or separated parents, benefits are determined in the following order:

  • The plan of the parent who has financial responsibility by court decree;
  • The plan of the stepparent who is the spouse or registered domestic partner of the parent who has custody of the child; and
  • The plan of the parent who does not have custody of the child.

When none of these rules establishes order, benefits are paid first by the plan that has covered the person for the longer period of time, except that a plan that covers a laid-off or retired employee is secondary to a plan that covers a person as an active employee.