Order of Benefit Determination

Use the first of the following rules which applies: 

1. Nondependent/dependent. The benefits of the plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the plan which covers the person as a dependent, except that, if the person is also a Medicare beneficiary and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is— 

A. Secondary to the plan covering the person as a dependent; and

B. Primary to the plan covering the person as other than a dependent (for example, a retired employee), then the benefits of the plan covering the person as a dependent are determined before those of the plan covering that person as other than a dependent; 

2. Dependent child/parents not separated or divorced. The rules for the order of benefits for a dependent child when the parents are not separated or divorced are as follows:

A. The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year;

B. If both parents have the same birthday, the benefits of the plan which covered the parent longer are determined before those of the plan which covered the other parent for a shorter period of time; 

C. The word birthday refers only to the month and day in a calendar year, not the year in which the person was born; and 

D. If the other plan does not have the rule described in subparagraphs

3. Dependent child/separated or divorced parents. If two (2) or more plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order: 

A. First, the plan of the parent with custody of the child; 

B. Then, the plan of the spouse of the parent with the custody of the child; and 

C. Finally, the plan of the parent not having custody of the child; 

D. If the specific terms of a court decree state that one (1) of the parents is responsible for the health care expenses of the child and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. The plan of the other parent or spouse of the other parent shall be the secondary plan(s). This subparagraph does not apply with respect to any claim determination period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge; or

E. If the specific terms of the court decree state that the parents shall share joint custody, without stating that one (1) of the parents is responsible for the health care expenses of the child, the plans covering the child shall follow the order of benefit determination rules outlined in paragraph (4)(B)2., dependent child/parents not separated or divorced;