COORDINATION OF BENEFITS (DUAL COVERAGE)

This coordination of benefits provision is designed to provide maximum coverage, but not to exceed 100 percent of the total fee for a given treatment plan.

Please note, for State of Michigan married employees both enrolled in the State Dental Plan, there is no coordination of benefits. However, coordination of benefits is available between the State Dental Plan and any other group dental plan.

The primary dental program (as specified below) will pay all of the benefits it would owe as if no other coverage was involved. The secondary program will then pay all of the benefits it would owe as if no other coverage was involved, up to 100 percent of the subscriber's liability under that plan. In no case is any program required to pay more than it would have paid without any coordination of benefits.

The program covering the patient as an ‘employee’ is primary over the program covering the patient as a ‘dependent’.

If a dependent child is covered by both parents, the plan covering the parent whose birthday occurs earliest in the calendar year is primary over the other parent’s plan. This birthday rule does not apply when the parents are divorced or legally separated, unless the specific terms of a court decree state that the parents will share custody without stating that one parent is responsible for the dental care expenses of the child. In cases where a court decree designates financial responsibility to one parent, the order of benefit determination is outlined below.

In the case of an enrolled dependent child of divorced or legally separated parents, claims will be paid in the following order of priority:

a) First, the plan covering the child as a dependent of the parent who, under the terms of a divorce decree, has the responsibility for the dental care of the child. In no event will a child be eligible for enrollment unless they meet the criteria in the Eligibility section.

b) Next, the plan covering the child as a dependent of the custodial parent.

c) Or next, the plan covering the child as a dependent of the custodial parent’s spouse.

d) Or the plan covering the child as a dependent of the non-custodial parent.

If the subscriber (you) is enrolled as a subscriber under more than one plan, the plan that has covered you the longest is primary over the other. However, a program that covers the subscriber as a laid-off or retired employee (or as the dependent of a laid-off or retired employee) will have a lower priority than a plan that does not.

Contact Delta Dental for information on alternative rules which may apply to dental plans issued outside of Michigan.

SUBROGATION

Under the State Dental Plan, the OSE Employee Benefits Division has the right to recoup benefits paid to or on behalf of participants through legal suit, if the action causing the medical expense was the fault of another individual or entity.

The enrolled participants will execute necessary documents or perform any other act required to secure this right to Delta Dental.

OBTAINING AND RELEASING INFORMATION

Delta Dental may obtain from any insurance company, group hospitalization plan, or dental care plan any information about payments or benefits related to any dental claim submitted. Any eligible person claiming benefits under this Plan will furnish Delta Dental any information that is necessary to implement this provision.

DENTIST-PATIENT RELATIONSHIP

The eligible person has freedom of choice of any licensed dentist. Each dentist rendering service under this Plan is an independent contractor and will maintain the dentist-patient relationship with his or her patient and will be responsible to the patient for dental advice and treatment and any resulting liability.