Coordinating Spouse Coverage Claims

You may be able to coordinate your benefits if your plan allows and if your Spouse also has coverage under another employer’s health and/or dental care plan. This means that as long as your Spouse has couple or family coverage, you can submit claims to his/her benefit plan (and vice versa). If one plan doesn’t refund 100% of your expenses, the other plan will refund you the difference, subject to the plan limits.

For example, if you have a dental claim for $100, and your dental coverage covers 80% of the cost of eligible dental expenses, you’ll be reimbursed for $80. If your Spouse has couple or family coverage under his or her plan, you can submit a claim to your Spouse’s plan for the remaining $20.

There are some rules about coordinating your health and/or dental benefits: Please note that you need to check that your plan allows Coordination of Benefits. Contact your Benefits Administrator to see whether your District’s plan includes this provision.

• To coordinate benefits with your Spouse, both of you must be covered under an employer’s health and/or dental care plan. At least one of you must have couple or family coverage.
• You can never receive a refund of more than 100% of your eligible expenses.
• You must always submit claims for expenses incurred for yourself to your benefits program first. Make sure you keep a photocopy of your receipts. If your refund is less than 100% of your costs, you can then submit a claim for the difference to your Spouse’s plan.
• Your Spouse must always submit claims for expenses incurred for himself or herself to his or her own plan first. If your Spouse’s refund is less than 100% of the expense, then your Spouse can submit a claim for the difference to your benefits program.
• Claims for your dependent children must go first to the plan of the parent whose birthday comes first in the calendar year. If the parents have the same birthday, submit the child’s claims to the plan of the parent whose first name comes first in the alphabet. If the parents are separated or divorced, the child’s claim must go first to the plan of the parent who has custody of the child.

You’ll receive an explanation of benefits from the first Insurer that processes the claim. You must attach this statement to your second claim form. You should also attach copies of your receipts.