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Community Agencies Benefit Plans

Community Agencies Benefit Plans

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Coordination of Benefits

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If the plan member is covered by more than one Extended Health Care or Dental Care plan, the member can co-ordinate benefits between both plans. The co-ordination of benefits allows the member to receive a reimbursement up to 100% of expenses incurred.

Claims for the plan member

As the plan member insured under this plan, submit all necessary claim forms and original receipts to the claims provider. Once the claim has been processed outlining the outcome, and if there is any balance outstanding, this portion can be sent to your spouse’s plan for further consideration of payment.

Claims for the plan member’s spouse

All necessary claim forms and original receipts are sent for reimbursement to the spouse’s plan provider. Once the claim has been settled, the spouse will receive an Explanation of Benefits (EOB). If there is any balance outstanding, that portion can be sent to the claims provider, along with a completed claim form, for further consideration of payment.

Claims for a dependent child

The claim must be submitted to the plan covering the parent whose birthday (month/day only) is earlier in the calendar year. That is, if an Agency’s plan member’s birthday is June 5 and the spouse’s birthday is March 19, the claim for the dependent child must be sent to the spouse’s plan first. If both birthdays fall on the same exact day and month, the claim must then go to the parent who is the older of the two.

If you are separated or divorced, the plan which will pay benefits for your children will be determined in the following order:

  • the plan of the parent with custody of the child;
  • the plan of the spouse of the parent with custody of the child;
  • the plan of the parent without custody of the child;
  • the plan of the spouse of the parent without custody of the child

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