IQVIA Benefits Handbook
WHICH PLAN PAYS FIRST
Court-Ordered Benefit Responsibility
Sometimes a court assigns responsibility to one parent for paying a child's health care expenses—for example, if there's a divorce. This order is called a qualified medical child support order (QMCSO). QMCSOs take precedence over all other rules, as long as the claims administrator of the plan covering that parent has knowledge of the QMCSO before benefits are paid in the plan year.
If you or a covered dependent has coverage under more than one plan, first submit your expenses to the primary plan, then submit them to the secondary plan. To determine which plan is primary:
  • For you: The IQVIA coverage is primary. Submit your health care expenses to the IQVIA plan first, then to the other plan.
  • For your spouse: Your spouse's employer-sponsored plan is primary, if he/she is enrolled. Submit your spouse's health care bills to his/her plan first, then to the IQVIA plan.
  • For your children: When a child is covered under both parents' plans, the plan of the parent whose birthday falls earlier in the calendar year pays benefits first. If you and your spouse have the same birthday, the plan that has been covering your child longer pays benefits first. If the other plan has not adopted this "birthday rule," that plan's order of determination rules determines which plan is primary.
  • If you're divorced, legally separated or remarried, the plans pay benefits in the following order:
    • First, if a court decree states that one parent is responsible for the child's healthcare expenses or health coverage and the plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge;
    • Then, the plan of the parent with custody.
    • Then, the plan of the spouse of the parent with custody.
    • Then, the plan of the parent without custody.
    • Finally, the Plan of the spouse of the parent not having custody of the child.
  • If you're covered under Medicare: If you or your dependent is covered by Medicare because of age, disability or end-stage renal disease, IQVIA coverage may be primary to Medicare coverage. Generally, if you're still working for IQVIA and you have Medicare coverage, the medical coverage you have through IQVIA is primary, so submit your medical bills to the IQVIA plan first. Then, submit any medical expenses not covered by the IQVIA plan to Medicare for payment. However, once your employment ends, Medicare becomes your primary plan in most cases.
  • Note that:
    • If one of the Plans that covers you is issued out of the state whose laws govern the IQVIA Policy, and determines the order of benefits based upon the gender of a parent, and as a result, the Plans do not agree on the order of benefit determination, the Plan with the gender rules shall determine the order of benefits.
    • If none of the above rules determines the order of benefits, the Plan that has covered you for the longer period of time shall be primary.
    • If you have been covered for the same amount of time by more than one IQVIA policy, the IQVIA self-funded plan shall be primary.
  • When coordinating benefits with Medicare, this Plan will be the Secondary Plan and determine benefits after Medicare, where permitted by the Social Security Act of 1965, as amended for the following:
(a) a former employee who is eligible for Medicare and whose insurance is continued for any reason as provided in this Plan;
(b) a former employee's dependent, or a former dependent spouse, who is eligible for Medicare and whose insurance is continued for any reason as provided in this Plan;
(c) an employee whose employer and each other employer participating in the employer's plan have fewer than 100 employees and that employee is eligible for Medicare due to disability;
(d) the dependent of an employee whose employer and each other employer participating in the employer's plan have fewer than 100 employees and that dependent is eligible for Medicare due to disability;
(e) an employee or a dependent of an employee of an employer who has fewer than 20 employees, if that person is eligible for Medicare due to age;
(f) an employee, retired employee, employee's dependent or retired employee's dependent who is eligible for Medicare due to End Stage Renal Disease after that person has been eligible for Medicare for 30 months;
    • Aetna will assume the amount payable under:
      • Part A of Medicare for a person who is eligible for that Part without premium payment, but has not applied, to be the amount he would receive if he had applied.
      • Part B of Medicare for a person who is entitled to be enrolled in that Part, but is not, to be the amount he would receive if he were enrolled.
      • Part B of Medicare for a person who has entered into a private contract with a provider, to be the amount he would receive in the absence of such private contract.
    • A person is considered eligible for Medicare on the earliest date any coverage under Medicare could become effective for him.
    • This reduction will not apply to any Employee and his Dependent or any former Employee and his Dependent unless he is listed under (a) through (f) above.
However, when more than one Plan is secondary to Medicare, the benefit determination rules identified above, will be used to determine how benefits will be coordinated.