Coordination of Benefits
The following information pertains to group health care plans that may be coordinating how benefits are paid between a Leidos health care plan and another plan.
Releasing and Obtaining Information
The health care plans reserve the right to release to, or obtain from, any other insurance company or other organization or person any information that, in its opinion, it needs for the purpose of coordination of benefits, provided that any and all determinations or actions described in the foregoing are subject to applicable law.
Subrogation and Reimbursement
This section applies when the Plan pays claims for the treatment of an illness, injury, or condition for which a third party is responsible (for example, when the Plan pays claims for the treatment of an illness, injury or condition caused by an automobile accident or another’s negligence). For purposes of this section, the term "third party" may include, but will not be limited to, any one or more of the following:
- the party or parties who caused the illness, injury, or condition;
- the insurer, guarantor, or other indemnifier of the party or parties who caused the illness, injury, or condition;
- the covered participant or dependent’s own insurer (for example, uninsured, underinsured, med-pay, no fault coverage, and homeowners);
- a worker’s compensation insurer; and/or
- any other person, entity, policy, healthcare plan, or insurer that is liable or legally responsible in relation to the illness, injury, or condition.
Because the Plan is entitled to reimbursement, the Plan shall be fully subrogated to any and all rights, recovery or causes of actions or claims that you or your covered Dependent may have against any third party.
Subrogation is the substitution of one person or entity in the place of another with reference to a lawful claim, demand or right.
The Plan is granted a specific and first right of reimbursement from any payment, amount or recovery from a third party. This right to reimbursement is regardless of the manner in which the recovery is structured or worded, whether in the form of a settlement (either before or after any determination of liability) or judgment, and even if you or your covered Dependent has not been paid or fully reimbursed for all of his or her damages or expenses. The proceeds available for reimbursement will include, but not be limited to, any and all amounts earmarked as non-economic damage settlement or judgment. You or your covered Dependent may not reduce the amount you owe the Plan to account for the payment of attorney’s fees or other obligations.
The Plan’s share of the recovery will not be reduced because the full damages or expenses claimed have not been reimbursed unless the Plan agrees in writing to such reduction. Further, the Plan’s right to subrogation or reimbursement will not be affected or reduced by the “make whole” doctrine, the “fund” doctrine, the “common fund” doctrine, comparative/contributory negligence, “collateral source” rule, “attorney’s fund” doctrine, regulatory diligence or any other equitable defenses that may affect the Plan’s right to subrogation or reimbursement.
The Plan may enforce its subrogation or reimbursement rights by requiring you or your covered Dependent to assert a claim to any of the benefits to which you or your covered Dependent may be entitled. The Plan will not pay attorney’s fees or costs associated with the claim or lawsuit without express written authorization from Leidos.
If the Plan should become aware that you or your covered Dependent has failed to comply with these provisions, the Plan, in its sole discretion, may (1) suspend all further benefits payments related to you or any of your Dependents until the reimbursable portion is returned to the Plan or offset against amounts that would otherwise be paid to or on behalf of you or your covered Dependents, (2) terminate health benefits, or (3) institute legal action against you (or your covered Dependents, if applicable).
Reimbursement from Third Party Recoveries
The participant or dependent agrees to repay the Plan first from any money or other benefit recovered from the third party who is, or may be held to be, liable or legally responsible for the illness, injury, or condition giving rise to the paid benefits. The obligation to repay applies:
- whether the payment received from the third party is the result of a legal judgment, arbitration award, compromise, settlement, or any other arrangement;
- regardless of whether the third party has admitted liability for the payment;
- regardless of whether the charges are itemized in the third party’s payment or whether the third party’s payment is structured as a settlement for pain and suffering or in any other manner which does not itemize charges;
- regardless of whether the participant or dependent has incurred, or agreed to pay, any costs or charges in relation to seeming the recovery from the third party; and
- regardless of whether the participant or dependent is made whole by the payment.
If such a recovery is made and the Plan is not reimbursed as required herein, then the participant, dependent, estate, or legal representative will be liable to the Plan for the amount of the benefits paid under the Plan for such illness, injury, or condition.
Subrogation of Rights Against Third Parties
Each participant and dependent transfers and assigns to the Plan the option, at the Plan’s sole discretion, to exercise all rights to take legal action against third parties arising from any illness, injury, or condition for which such third parties are or may be held liable or legally responsible. That is, the Plan may take over the participant's and dependent's right to receive payments from the third party to the extent of the benefits paid or payable plus the Plan's reasonable costs of collection. This includes, without limitation, the right to any recovered funds paid by any other party to a participant or dependent or paid on behalf of a participant or dependent, or on behalf of the estate of any participant or dependent.
The participant or dependent agrees to cooperate fully in asserting the Plan's subrogation and recovery rights against the third party. The participant, dependent, or his or her legal representative will, within 5 days of receiving a request from the Plan, provide all information and sign and return all documents necessary to exercise the Plan's rights under this provision.
Please note the following:
- Participants and dependents are required to abide by the terms of this section. Failure to do so may result in immediate termination of coverage.
- The Plan's rights to reimbursement and subrogation, and any recovery pursuant to those rights will not be reduced: (a) due to the participant's or dependent's own negligence; (b) due to the participant's or dependent's not being made whole; (c) or by any portion of a participant's or dependent's attorney's fees and costs.
- The Plan is not responsible for any attorney fees, attorney liens, or other expenses or costs.
- No equitable claims or defenses of any kind apply to the Plan's right to reimbursement and subrogation ( or to any recovery pursuant to these rights), including but not limited to offset, detrimental reliance, equitable and promissory estoppel, the ''make whole" doctrine, and the ''common fund" doctrine.
- The participant and dependent will cooperate in assisting the Plan in protecting the Plan's rights to reimbursement and subrogation and will not act or fail to act at any time or in any manner that prejudices the Plan's rights under this provision (including settling a claim with a third party without advance notice to the Plan).
- The Plan has the right to recover interest at the rate of 1.5% per month or the maximum amount permitted by law, whichever is less, on the amount paid by the Plan because of the illness, injury, or condition.
- The Plan is secondary to any excess insurance policy including, but not limited to, school and/or athletic policies.
- If the participant or dependent resides in a state where no-fault coverage, or automobile personal injury protection or medical payment coverage is mandatory, that coverage is primary, and the Plan takes secondary status. The Plan will reduce benefits for an amount equal to, but not less than, the state's mandatory minimum personal injury protection or medical payment requirement.
- This provision also applies to any funds recovered from the third party by or on behalf of: (i) a minor dependent; (ii) the estate of any participant or dependent; and (iii) any incapacitated person.
- The Plan's lien exists at the time the Plan pays benefits, and if a participant or dependent files a petition for bankruptcy, he or she agrees that the Plan's lien existed prior to the creation of the bankruptcy estate.
- Failure by a participant or dependent to cooperate with the Plan in the exercise of these rights may also result, at the discretion of the Plan, in a reduction of future benefit payments available to a participant or dependent under the Plan by an amount, up to the aggregate amount paid by the Plan that was subject to the Plan's equitable lien, but for which the Plan was not reimbursed. In certain circumstances, the Plan also may be entitled to recover any of the unsatisfied portions of the amount the Plan has paid or the amount of your recovery, whichever is less, directly from the medical providers to whom the Plan has made payments on your behalf. In such a circumstance, it may then be your obligation to pay the provider the full billed amount, and the Plan will not have any obligation to pay the provider or reimburse you.
Assignment of Benefits
Except as otherwise provided in the Plan, in a Qualified Medical Child Support Order (“QMCSO”), or pursuant to a voluntary assignment of benefits to a health care provider or facility providing health care services covered by the Plan, no benefit, right or interest of any covered person under the Plan shall be subject to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance, charge, garnishment, execution or levy of any kind, either voluntary or involuntary, including any liability for, or subject to, the debts, liabilities or other obligations of such person; and any attempt to anticipate, alienate, sell, transfer, assign, pledge, encumber, charge, garnish, execute or levy upon, or otherwise dispose of any right to benefits payable hereunder or legal causes of action, shall be void. Notwithstanding the Plan may choose to remit payments directly to health care providers with respect to covered services if authorized by the covered person, but only as a convenience to covered persons. Health care providers are not, and shall not be construed as, either “participants” or “beneficiaries” under this Plan and have no rights to receive benefits from the Plan or to pursue legal causes of action on behalf of (or in place of) covered persons under any circumstances.
If the Plan Administrator or Claims Administrator (as applicable) cannot locate an individual covered under the Plan, after making a reasonably diligent effort, including by giving written notice addressed to the individual's last known address as shown by the records of the Plan, the amount payable to the individual is forfeited.
If a check to you for benefits under the Plan remains uncashed for 90 days after issue, amounts attributable to such check shall be forfeited to the Plan. In such event, you shall have no further claim to such amount for any reason.
Access to Records
By enrolling for coverage under the Plan, you authorize the Plan Administrator, Claims Administrator and their representatives (collectively the “Administrators”) to have access to any records and medical information held by any provider who delivers services to you under the Plan. You also authorize the Administrators to use your records and medical information for claims processing, including, without limitation, claims by the Company for reimbursement or subrogation under the Plan; medical care claims data evaluation; quality of care assessment; medical service utilization review; and evaluation of potential or actual claims against the Administrators.
Recovery of Overpayment
Payments are made in accordance with the provisions of the Plan. If it is determined that payment was made for an ineligible charge or that other insurance was considered primary, the Plan has the right to recover the overpayment. The Plan will try to collect the overpayment from the party to whom the payment was made. However, the Plan reserves the right to seek overpayment from any participant, beneficiary, or dependent. In addition, the Plan has the right to engage an outside collection agency to recover overpayments on the Plan’s behalf if the Plan’s collection effort is not successful. The Plan may also bring a lawsuit to enforce its rights to recover overpayments.
If the overpayment is made to a provider, the Plan may reduce or deny benefits, in the amount of the overpayment, for otherwise covered services for current or future claims with the provider on behalf of any participant, beneficiary, or dependent in the Plan.
No Surprises Act
The following terms will apply to applicable Plan coverage, to the extent not otherwise described in any Benefits Booklets/Summaries:
Emergency Medical Condition: For purposes of the Plan, emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of medical attention to result in a condition described in the federal Emergency Medical Treatment and Labor Act (“EMTALA”), including: (1) placing the health of the individual or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part.
Visit: For purposes of the Plan, the scope of “visit” to a participating health care facility is expanded as necessary to include the furnishing of equipment and devises, telemedicine services, imaging services, laboratory services, and preoperative and postoperative services, regardless of whether the provider furnishing such items or services is at the facility.
Independent Dispute Resolution Process When Open Negotiations Fail to Result in an Agreed Upon Out of Network (“OON”) Rate for OON Claims in Which Balance Billing is Prohibited. Providers, facilities and air ambulance providers will meet deadlines, attest to no conflicts of interest, choose a certified independent dispute resolution entity, submit a payment offer and provide additional information if needed. Providers, facilities and air ambulance providers agree to utilize the DOL’s mandatory notices and use the federal independent dispute resolution (“IDR”) internet-based portal.
Air Ambulance Billing: When a Plan participant receives air ambulance services from a nonparticipating provider and such services would be covered by the Plan if provided by a participating provider, the Plan shall: (i) calculate cost-sharing with respect to these services as though such services were obtained from a participating provider; (ii) calculate cost-sharing based on the lesser of the Qualifying Payment Amount (“QPA”) or the billed amount for the services; (iii) count the cost-sharing amounts toward the in-network deductible and in-network out-of-pocket maximum; and (iv) pay to the provider an initial payment or send a notice off denial within 30 days after the bill is received and pay the total amount due directly to the provider. Any disputes between the air ambulance service provider and Plan shall be resolved through the open negotiation and IDR process.
Continuing Care Patient: A “continuing care patient” is defined as an individual with respect to a provider or facility who is: (i) undergoing a course of treatment for serious and complex condition from the provider or facility; (ii) undergoing a course of institutional or inpatient care from the provider of facility; (iii) scheduled to undergo non-elective surgery from the provider or facility, including postoperative care with respect to such facility; (iv) pregnant and undergoing a course of treatment for the pregnancy; or (v) determined to be terminally ill and is receiving treatment for such illness.
External Review: All external reviews shall, as applicable, be conducted in accordance with the requirements of the No Surprises Act (including all implementing guidance and regulations). Please contact the Plan Administrator for additional information about this external-review process.
Interpretation & Governance
The Plan Administrator has the exclusive discretionary authority to determine all matters relating to interpretation and operation of the plan, including eligibility, coverage and benefits. The Plan Administrator may delegate any of its duties and responsibilities to one or more persons or entities. Such delegation of authority must be in writing and must identify the delegate and the scope of the delegated responsibilities. Decisions by the Plan Administrator, or any authorized delegate, will be conclusive and legally binding on all parties.
Leidos reserves the right to change, amend, suspend, or terminate any or all of the benefits under the plan, in whole or in part, at any time for any reason in its sole discretion, by action of a designated corporate officer or employee delegated authority for such actions by the Leidos Board of Directors. Leidos’ rights include the right to obtain coverage and/or administrative services from additional or difference insurance carriers, third party administrators, etc., and the right to revise the amount of employee contributions. Employees will be notified of any material modifications to the plan. Nothing in this document says or implies that participation in the Plan is a guarantee of continue employment, nor is anything in this document intended to guarantee that benefit levels or costs will remain unchanged in future years.
Leidos cannot advise you regarding tax, investment or legal considerations relating to the plan. Therefore, if you have questions regarding benefit planning, you should seek advice from a personal advisor (e.g., legal counsel, tax advisor, investment advisor).
Questions concerning the plan can be directed to the Plan Administrator. A copy of the plan document is available for your inspection upon request.