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Coordination of Benefits
Under HIPAA , HHS adopted standards for electronic transactions, including for coordination of benefits.
The coordination of benefits transaction is the transmission from any entity to a health plan for the purpose of determining the relative payment responsibilities of a health plan for health care claims or payment information. See the Coordination of Benefits Transactions Basics.
About Coordination of Benefits
Coordination of benefits (COB) applies to a person who is covered by more than one health plan.
The COB regulations, as well as the HIPAA Privacy Act, permit Medicare to coordinate benefits with other health plans and payers to reduce administrative burden and enable patients to obtain payment of the maximum benefit they are allowed. The same applies in situations where Medicare is the secondary payer and a provider must file a COB claim to Medicare.
COB claims are those sent to secondary payers with claims adjudication information included from a prior or primary payer (the health plan or payer obligated to pay a claim first). These claims can be sent 1) from provider to payer to payer or 2) from provider to payer. Additional information about Medicare's COB/claims crossover process is available.
HIPAA Adopted Standards
In January 2009, HHS adopted Version 5010 of the ASC X12N 837 for coordination of benefits. For more information, see the official ASC X12N website.
For COB pharmacy claim transactions, HHS adopted NCPDP Telecommunications Standard Version D.0.
These standards apply to all HIPAA-covered entities , health plans, health care clearinghouses, and certain health care providers, not just those who work with Medicare or Medicaid.
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- Understanding My Benefits
What's coordination of benefits?
Who is this for.
Blue Cross Blue Shield of Michigan and Blue Care Network members under age 65.
Sometimes two insurance plans work together to pay claims for the same person. That process is called coordination of benefits. Insurance companies coordinate benefits to:
- Avoid duplicate payments by making sure the two plans don’t pay more than the total amount of the claim
- Establish which plan is primary and which plan is secondary—the plan that pays first and the plan that pays any remaining balance after your share of the costs is deducted
- Help reduce the cost of insurance premiums
When one person has two health insurance plans
You have custody of your 8-year-old son. He’s on your health insurance plan and your ex-husband’s plan. When your son goes to the doctor, we’ll review the claim to figure out which plan is primary and which plan is secondary.
That’s coordination of benefits.
Health insurance and auto insurance
You hit a deer with your car, hurt your knee and need to go to a doctor. Michigan auto insurance policies must include coverage for car-related injuries, called personal injury protection. But in most cases your health insurance is primary. So your health plan will pay first, and if there are expenses left over not covered by your plan, your auto insurance will pay those.
That’s coordination of benefits, too.
Subrogation
Coordination of benefits also happens when you’re injured and it’s not your fault. Here’s an example.
You’re in a store and slip on a wet floor. You hurt your elbow and need to go to a doctor. Because the accident wasn’t your fault, your health insurance company will contact the store’s insurance company to get them to help pay for your care.
The process of getting the other insurance company to pay is called subrogation.
If we contact you about coordination of benefits or subrogation
When we send you a form that asks if you have more than one health insurance plan, you should respond, even if the answer is no.
You don’t have to wait for us to contact you. You can:
- Let us know anytime you or anyone on your plan adds or drops other health insurance
- Confirm your existing coordination of benefits information or update it when your plan renews each year; then we won’t mail you a form
If we contact you about subrogation, you should also respond. Learn more about subrogation .
Related Items
- Coordination of Benefits Form
- Subrogation Form
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Coordination of Benefits: Everything You Need to Know
COB, or coordination of benefits, occurs when an individual is in possession of more than one insurance policy and it comes to processing a claim. 4 min read
Also referred to as COB, coordination of benefits occurs when an individual is in possession of more than one insurance policy and when it comes to processing a claim, the policies are assessed to determine which will be assigned with the primary responsibility for covering the predominant share of the claim costs.The process also involves assessing the extent that other policies held will contribute toward the claim. This article will provide you with everything that you need to know about coordination of benefits.
What Is Coordination of Benefits?
The primary intentions of coordination of benefits are to make sure that individuals who receive coverage from two or more plans will receive their complete benefit entitlement and to prevent benefits from being duplicated when an individual has more than one policy in place. This process covers insurance pertaining to several sectors including health insurance, car insurance, retirement benefits, workers compensation, and others.
The order in which the insurance policies are coordinated is dictated by insurance law and cannot be decided by a company or an individual. This process takes place only when multiple insurance plans are involved. If only one plan is held, then all responsibility is put onto the sole plan.
Predominantly, coordination of benefits happens when an individual has two plans in place (primary and secondary), but it may also include a tertiary plan in some circumstances. The primary insurance plan is given the responsibility of being the first payer, the secondary plan is the second payer, and so on depending on how many plans the individual holds.
Why Is COB Important?
There are numerous reasons why COB is an important process. These are summarized below:
- A lack of coordination between the plans a person holds can result in the claim not being paid until the COB has been confirmed, thus potentially causing financial difficulties.
- Either the individual or the insurance provider could be subjected to expenses that they did not need to pay if the insurance plans are not coordinated correctly.
Order of Benefit Determination
The primary plan is always considered as the predominant provider of benefits, and it must provide these as though the claim holder does not have a second or third policy in place. The COB provisions that are specified in the insurance policy outline which plan is the primary plan. Once identified, the primary plan's benefits are applied to the claim first.
It is important to note that the primary plan is always considered as the first payer, regardless of the specifics written in its clauses. This means that any plan that does not include the COB provisional clause may not incorporate the benefits offered by a claimant's other plan into their considerations when assessing what benefits are due.
Any unpaid balance owed to the patient is typically paid by the claimant's second plan, within the limits of its responsibility. This secondary insurance plan can take the benefits of the patient's other plans into consideration only when it has been confirmed as being the secondary — not primary — plan.
The payments that are delivered to the patient by their combined insurance plans do not exceed 100 percent of the charges for necessary covered services. The benefits are usually coordinated between all of the plans held by the patient.
If a family is making a claim, each individual and their COB will be assessed separately, as there is a possibility that the order of plans and benefits may differ between each member.
There may be some differences to the "order of benefit determination" as laid out here if the claimant's policy is held with Medicare, but otherwise, these rules should be followed as a standard process.
Understanding Various COB Rules
Common COB circumstances and how the COB rules are then applied are outlined below.
- Plan Type Rule If the individual has both a commercial insurance plan and Medicaid, then the commercial plan will always be considered as the primary policy, and Medicaid is secondary.
- Subscriber or Dependent Rule If a patient subscribes to two or more policies, where one policy is as a subscriber, and another is as a dependent, then the policy under which they are classified as a subscriber is the primary policy, and that where they are a dependent will fall as the secondary policy.
- Timeline Rule If the patient is the primary subscriber to two commercial plans, then the plan to which they have been subscribed the longest is considered as the primary plan, and the newer plan is the secondary.
- Employer Coverage Rule If the individual has coverage both through their employer and as a dependent through another commercial plan, then the employer-operated plan will always be considered as the primary plan.
- 1. The birthday rule of the parent (whoever's occurs earlier in the year) and,
- 2. The length of policy rule of the policy holders (whichever commenced first).
- Dependent Child (Parents Not Separated or Divorced) Rule If a child's parents are together, then determining the primary plan is done by using the birthday rule (i.e. whoever was born earlier is responsible).
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Missing Piece Blog
What is coordination of benefits and why is it important.
Some individuals are fortunate enough to have coverage from two health insurance plans. But what happens when two insurers both provide the same cover to a patient? This is when a process known as Coordination of Benefits ( COB ) comes into effect.
What is coordination of benefits in insurance?
When patients are eligible for benefits under two or more health insurance plans, the insurers will “coordinate” benefits to establish proper claims processing. The COB process begins with the insurance companies determining the primary and secondary (or tertiary in rare situations) plan for a patient. Once this has been determined, the primary plan will pay for services according to their provided benefits, while the secondary or tertiary plan will pay for any remaining costs for services according to their provided benefits.
When is coordination of benefits needed?
Coordination of benefits should be completed by each member with more than one policy on an annual basis. Common reasons for the coordination of benefits to be requested by insurance are:
- When an individual is covered by their employer’s policy and is also covered under their spouse’s plan.
- When an individual has a private or marketplace plan, but has an additional plan through a spouse or parent.
- When a child is covered by more than one parent, stepparent, or guardian.
- When a patient has Medicare or Medicaid in addition to being covered by a commercial insurance plan.
How are benefits coordinated?
We’ve already briefly touched on how insurers will engage with each other to decide on which health insurance plan is primary and which is secondary. However, there are other elements that could affect how benefits are coordinated. These factors are:
- If an individual is covered by their employer’s policy, this policy will pay before a policy where the individual is considered a dependent.
- If the child/dependent is covered by multiple parents/guardians, the plan of the parent/guardian with the earlier birth date in the calendar year pays first. In some instances, a custody or court order might supersede the date of birth rule.
- If the child/dependent has coverage through an employer or post-secondary institution, these plans will always pay before a plan where the child is the dependent.
- Policy holders need to complete the coordination of benefits form with each insurance company and are obligated to disclose all policies. Claims may be held if coordination of benefits forms are not completed by policy holders. Policy holders must also communicate changes in coverage to their insurance company.
- Many children with autism or other disabilities are covered by Medicaid and/or additional funding sources. Typically, Medicaid is considered the payer of last resort. The patient’s parent/guardian is still obligated to disclose coverage to all insurers, and they will coordinate benefits.
Why is coordination important?
The necessity of COB for insurance providers and patients can’t be overlooked. Coordination helps both insurers and patients deal with many challenges including:
- Preventing both insurance companies paying for the same claim.
- Helping reduce the cost of insurance premiums.
- Helping the provider understand which policy to bill as primary, secondary, or tertiary.
- Helping keep the cost of prescription medication as affordable as possible.
- Avoiding any situations where a patient or insurer has to pay for expenses due to a lack of coordination
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To learn more about how our comprehensive revenue cycle management process helps ABA services , including in situations requiring coordination of benefits, contact us online or by phone at 765-628-7400.
What does "Coordination of Benefits" Mean Anyway?
Main Points
Coordination of benefits (COB) allows an insurance plan to know where they fall in the reimbursement chain
A miscommunication in coordination of benefits can inhibit insurance companies from paying on claims
The way an insurance company knows the coordination of benefits can vary, and the patient is ultimately responsible for knowing their benefits
One of the most misunderstood denial reasons that providers receive is called "coordination of benefits". What does that mean? What am I supposed to do about that? If I told my patient, what would they do with that information?
The disorienting nature of this denial reason lends itself to delaying payment as long as possible from the insurance company. The problem is that the term "coordination of benefits" doesn't communicate what the patient should do, what the provider should do, or what the biller should do to resolve the issue.
In this blog we are going to flesh out the term "coordination of benefits" and what you should do if you receive a denial with this designation. It will be important that you communicate clearly to your patient that way they know exactly what they need to do and who they need to communicate with.
First, let's define the term "coordination of benefits". Coordination of benefits is the process that allows a plan to determine their respective payment responsibilities . Basically, if a patient has multiple insurance plans that are active, which one is responsible for covering the patient first, second, and third.
There can be quite a bit of confusion around which insurance company pays first.
The COB process is beneficial for several reasons:
Ensures claims are paid correctly by identifying the health benefits available to a Medicare beneficiary, coordinating the payment process, and ensuring that the primary payer, whether Medicare or other insurance, pays first.
Shares Medicare eligibility data with other payers and transmits Medicare-paid claims to supplemental insurers for secondary payment. Note: An agreement must be in place between the Benefits Coordination & Recovery Center (BCRC) and private insurance companies for the BCRC to automatically cross over claims. In the absence of an agreement, the person with Medicare is required to coordinate secondary or supplemental payment of benefits with any other insurers he or she may have in addition to Medicare.
Ensures that the amount paid by plans in dual coverage situations does not exceed 100% of the total claim, to avoid duplicate payments.
Accommodates all of the coordination needs of the Part D benefit. The COB process provides the True Out of Pocket (TrOOP) Facilitation Contractor and Part D Plans with the secondary, non-Medicare prescription drug coverage that it must have to facilitate payer determinations and the accurate calculation of the TrOOP expenses of beneficiaries; and allowing employers to easily participate in the Retire Drug Subsidy (RDS) program.
However, this process can be a bit confusing and complicated to navigate.
The way an insurance company knows the coordination of benefits can vary, and the patient is ultimately responsible for knowing their benefits . Here is a breakdown of where COB data can come from or get communicated:
COB Data Sources:
COB relies on many databases maintained by multiple stakeholders including federal and state programs, plans that offer health insurance and/or prescription coverage, pharmacy networks, and a variety of assistance programs available for special situations or conditions. Some of the methods used to obtain COB information are listed below:
IRS/SSA/CMS Claims Data Match - The law requires the Internal Revenue Service (IRS), the Social Security Administration (SSA), and CMS to share information about beneficiaries and their spouses. By law, employers are required to complete a questionnaire, the IRS/SSA/CMS Data Match, on the group health plan that Medicare-eligible workers and their spouses choose. The Data Match identifies situations where another payer is primary to Medicare. In addition, CMS has entered into Voluntary Data Sharing Agreements with numerous employers. These agreements allow employers and CMS to send and receive group health plan enrollment information electronically.
Voluntary Data Sharing Agreements (VDSAs) - CMS has entered into VDSAs with numerous large employers. These agreements allow employers and CMS to send and receive group health plan enrollment information electronically. Where discrepancies occur in the VDSAs, employers can provide enrollment/disenrollment documentation. The VDSA data exchange process has been revised to include Part D information, enabling VDSA partners to submit records with prescription drug coverage be it primary or secondary to Part D. Employers with VDSAs can use the VDSA to submit their retiree prescription drug coverage population which supports the CMS mission of a single point of contact for entities coordinating with Medicare.
COB Agreement (COBA) Program - CMS consolidates the Medicare paid claim crossover process through the COBA program. The COBA program established a national standard contract between the BCRC and other health insurance organizations for transmitting enrollee eligibility data and Medicare paid claims data. This means that Medigap plans, Part D plans, employer supplemental plans, self-insured plans, the Department of Defense, title XIX state Medicaid agencies, and others rely on a national repository of information with unique identifiers to receive Medicare paid claims data for the purpose of calculating their secondary payment. The COBA data exchange processes have been revised to include prescription drug coverage.
Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) – This law added mandatory reporting requirements for Group Health Plan (GHP) arrangements and for liability insurance, including self-insurance, no-fault insurance, and workers' compensation. Insurers are legally required to provide information.
Other Data Exchanges - CMS has developed data exchanges for entities that have not coordinated benefits with Medicare before, including Pharmaceutical Benefit Managers (PBMs), State Pharmaceutical Assistance Programs (SPAPs), and other prescription drug payers. CMS has worked with these new partners to educate them about coordination needs, to inform CMS about how the prescription drug benefit world works today, and to develop data exchanges that allow all parties to efficiently serve our mutual customer, the beneficiary.
A miscommunication in coordination of benefits can inhibit insurance companies from paying on claims . Obviously, there are several ways in which insurance companies can know how a patient is covered, which means there are several points where error can creep in and muddle the process.
Therefore, there are several rules of thumb when it comes to determining which insurance company pays first and which insurance company pays second.
The first rule of thumb is called the birthday rule. This is a default principle that the insurance companies use to determine when a dependent is covered by two parents. Basically, whichever parent's birthday falls earlier in the year, that is the primary insurance. For example, if a child's dad's birthday is February 1st and the mom's is March 1st, the dad's insurance is primary and the mom's is secondary, even if the mom is older.
The second rule of thumb comes down to whether the patient has a commercial payer or a government payer. If the patient has a commercial payer, that payer is first. Then the government payer is last. This is not always true, but it is true in most cases. If the patient has two government payers then Medicaid is ALWAYS the payer of last resort.
COB issues can be pervasive and can cause payment delays, but asking your patients and knowing where COB information comes from can lead to clear and evident reimbursement. You will want to be very clear with the patient when it comes to COB issues and denials and tell them to follow up with their insurance if you believe there is a problem.
If you find that you are still confused by COB issues or laws concerning COB, please reach out to us and we would be happy to clear up any confusion that you may have.
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Coordination of Benefits
Tips for reducing payment delays and improving accounts receivable.
One of the major reasons for delays in claims processing is the need for information to support coordination of benefits. Coordination of benefits (COB) applies to a person who is covered by more than one health plan. The COB provision and regulations require that all health plans and other payers (e.g., Medicaid and Medicare) coordinate benefits to eliminate duplication of payment and assist patients to receive the maximum benefit to which they are entitled. By adhering to the COB provisions, the health plans and other payers can determine which plan will pay for a claim first.
The health plan or payer obligated to pay a claim first is called the "primary" payer and the other plan or payer is termed "secondary." Together, the primary and secondary payers coordinate payments for services up to 100% of the covered charges at a rate consistent with the benefits. When information about all potential sources of coverage is not available to plans and payers, claims will generally be "pended" and remain unpaid until complete COB information is on file.
Top reasons for COB-related delays in payment include: (1) incomplete or inaccurate COB information on file with the plan or payer, and (2) failure to attach the Explanation of Benefits (EOB) from the primary payer when billing the secondary payer. In addition, one of the leading reasons for claim denials is failure to submit complete and clean claims. The following tips are designed to assist physicians/providers and their billing staff to reduce payment delays attributed to COB-related problems:
1. Ask All Patients About Secondary Insurance Coverage
Have an office procedure to collect and/or confirm primary and secondary insurance information at each visit. Ask patients to provide the following information about their spouse and/or dependents: social security number; birth date; group/policy number for other medical coverage (if applicable); and Medicare or Medicaid ID card (if applicable). Collect this information at the time the appointment is booked to allow time for your staff to confirm eligibility prior to the visit.
2. Know What Plans and Payers Need to Pay Claims
Although each plan and payer may have slightly different requirements, there are some requirements that are nearly universal. For example, nearly all plans require a copy of the EOB from the primary payer prior to paying a claim as the secondary payer. Most plans and payers publish their requirements and the information should be available in physician/provider manuals, online and by contacting physician/provider representatives.
3. Determine Primary and Secondary Payers
It is important for physicians/providers to determine primary and secondary payers so that claims can be sent to the primary payer first. Some plans will be able to tell physicians/providers whether they are primary or secondary at the time the physician/provider contacts the plan to verify eligibility. Typically, the following rules are used by plans and payers to determine the primary and secondary payer:
- The payer covering the patient as a subscriber will be the primary payer.
- If the patient is a dependent child, the payer whose subscriber has the earlier birthday in the calendar year will be the primary payer. This is known as the Birthday Rule.
4. Attach EOB from Primary Payer When Submitting Claim to Secondary
Secondary payers must have a copy of the Explanation of Benefits (EOB) provided by the primary payer to process and pay a claim. Make attaching an EOB to claims filed with secondary payers a part of your routine office procedure.
A special consideration for Medicare claims
Many health plans receive Medicare claims automatically when they are the secondary payer. In this case, the Explanation of Medicare Benefits (EOMB) will indicate that the claim has been automatically crossed over for secondary consideration. Physicians/Providers should look for this indication on their EOMBs and should not submit a paper claim to the secondary payer. A paper claim submitted in this circumstance would be coded as a duplicate and rejected by the secondary payer.
A committee representing health plans and health care physicians/providers prepared this document. Organizations that participated in the development of this document include American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American Academy of Dermatology Association, Bethesda Healthcare System, Piedmont Hospital, Group Health Incorporated, and Health Alliance Plan. America's Health Insurance Plans and the Healthcare Financial Management Association convened the committee.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.
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Coordination of benefits: Benefits of having two health insurance plans
Nupur Gambhir is a content editor and licensed life, health, and disability insurance expert. She has extensive experience bringing brands to life and has built award-nominated campaigns for travel and tech. Her insurance expertise has been featured in Bloomberg News, Forbes Advisor, CNET, Fortune, Slate, Real Simple, Lifehacker, The Financial Gym, and the end-of-life planning service.
John is the editorial director for CarInsurance.com, Insurance.com and Insure.com. Before joining QuinStreet, John was a deputy editor at The Wall Street Journal and had been an editor and reporter at a number of other media outlets where he covered insurance, personal finance, and technology.
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Some people are covered by two health insurance plans, which is called coordination of benefits (COB). If you have two plans, one will be primary and one will be secondary.
Coordination of benefits (COB) allows you to have multiple health insurance plans . COB allows insurers to determine which insurance company will be the primary payer and which will be the secondary if you have two separate plans . It also makes sure insurance companies don’t duplicate payments or reimburse for more than the health care services cost.
Key Takeaways
- Health insurance plans have a coordination of benefits system when the member has multiple health plans.
- The health plan that pays first depends on the type of plan, size of the company and location.
- The two insurers pay their portions of the claim and then the member pays the rest of the bill.
- What is coordination of benefits?
Coordination of benefits creates a framework for the two insurance companies to coordinate benefits so they pay their fair share when both plans pay. COB decides which is the primary insurance plan and which one is secondary insurance. You can think of the secondary payer as supplemental coverage to help you pay for out-of-pocket costs.
- How does coordination of benefits work?
If you are using coordination of benefits for their health insurance, the primary insurance pays its share of your health care costs first. Then, the secondary insurance plan will pay up to 100% of the total cost of health care, as long as it’s covered under the plan. Neither plan will pay more than 100% of the total health care costs, so you’re not going to get double the benefits if you have multiple health insurance plans.
- Coordination of benefits rules
COB rules vary for each individual and depend on the size and type of your plans, as well as what state you live in, as many states also have different laws in place. Additionally, large employers may have their own COB rules for medical claims.
- Medicaid and Medicare : Typically, Medicaid only pays as a last resort when there are multiple plans. But medicare can be primary or secondary, depending on the circumstances. For instance, Medicare is the primary payer if the other insurer is a small business, but it’s secondary when the other payer is a large company.
- Employer-sponsored plans : If you and your spouse have employer health plans , your employer is generally the primary payer for you and your spouse’s plan is secondary.
- Workers’ compensation : The worker’s comp pays first and your health insurance plan would is considered secondary.
- Veterans Administration (VA) and a private health insurance plan : VA is not considered a health insurance plan. Instead, the VA bills public or private health insurance providers for care, services, prescriptions and supplies. So, if your spouse has a health insurance plan, it would be your health plan.
- Military coverage (TRICARE) and other health insurance : TRICARE is considered secondary to all other health plans, except Medicaid, TRICARE supplements, state crime compensation programs and other specified federal government programs. Note: If you are on active duty, you can’t use any other health insurance. TRICARE is your only health insurance coverage.
- Understanding the coordination of benefits system
Here’s an example of how the process works:
- Let’s say you visit your doctor and the bill comes to $100.
- The primary plan picks up its coverage amount. Let’s say that’s $50.
- Then, the secondary insurance plan picks up its part of the cost up to 100% — as long as the insurer covers the health care services.
- You pay whatever the two plans didn’t cover.
That sounds great, right? Well, having two health plans also means that you’ll likely need to pay two premiums and deal with deductibles for two health plans. But, couples may choose to have two plans if they are both employer-sponsored.
- When coordination of benefits is needed
There are various situations when two health insurers need to coordinate on medical claims. You and your spouse may be eligible for two different policies from your jobs. Your spouse might be on Medicare and you have your own health plan. You might be under 26 and have your employer’s coverage and a parent’s insurance.
Here is a list of situations and which plan would likely serve as primary insurer and which ones would probably be secondary:
- Examples of coordination of benefits for dependents
Coordination of benefits can sometimes get complicated — especially if the healthcare plan is for a child or dependent. Here are just a few examples of how coordination of benefits works for dependents:
- A child has dual coverage by married parents : In this case, the birthday rule will apply, which states that whichever parent has the first birthday in a calendar year is the one whose insurance plan is considered primary. It’s not who is oldest — it’s where the birthday (month and day) falls in the calendar year. If parents have the same birthday, the primary coverage will go to the plan that has covered a parent longer.
- A child has divorced parents : The child is usually covered by the parent who has custody. If the child’s custodial parent remarried, the step-parent’s plan may provide secondary coverage for the child. The plan of the parent who doesn’t have custody usually pays last. If it’s joint custody, then the birthday rule usually applies. Additionally, a divorce decree may also influence which plan is primary. If the divorce states that one parent is financially responsible for the child’s healthcare expenses, that parent’s plan should be primary for the child and the other parent’s policy is secondary.
- A child under 26 is pregnant and on a parent’s plan : The health insurance status would stay the same for the child who is under 26; the parent’s insurance serves as secondary. However, it works differently for newborns. Once the child is born, they will need to be covered by their parent – not their grandparent.
- What are the different types of coordination of benefits?
Coordination of benefits is not one size fits all — there are a few different types of COB coverages:
- Carve out : The amount your primary plan paid is deducted from how much your primary plan can pay.
- Non-duplication : If the primary health insurance plan paid an amount that is equal to or more than what the secondary plan would pay, then the secondary plan does not pay out at all.
- Traditional: Your health insurance plans combined can cover up to 100% of your medical expenses.
You should discuss your best options and what your coordination of benefits offers with your benefits administrator or health insurance company.
- Frequently Asked Questions
Can you have two health insurances?
Yes, you can have more than one health plan.
Having two health plans may mean having to pay two premiums. However, two health plans may also help reduce out-of-pocket expenses when you need health care.
What is secondary insurance?
Secondary insurance is the health plan that pays second as part of the COB process.
The health plan that pays first and which one pays second depends on the type of plans and the situation. Check the table earlier on the page to see some of the scenarios.
How do I update my Medicare coordination of benefits?
There are a few different ways to update your Medicare coordination of benefits. For starters, reach out to your employer or union benefits administrator to update your benefits. If you still need help, try calling the benefits coordination hotline at 1-855-798-2627.
How does coordination of benefits work in health insurance?
COB is a process that decides which health plan pays first when you have multiple health insurance plans. These plans are called primary and secondary plans.
Who is responsible for coordination of benefits?
The health insurance plans handle the COB. The health plans use a framework to figure out which plan pays first — and that they don’t pay more than 100% of the medical bill combined.
The plan type guides a COB. Factors that play a part in deciding which plan pays first are based on the state and size and type of the type of plan. Large employer plans can create their own rules.
What is coordination of benefits in medical billing?
COB helps insurance companies with the medical claims billing process.
After you receive health care services, the provider bills the insurance company or companies. The primary insurance company reviews the claims first and decides what it owes. Then, the secondary plan reviews what’s left of the bill and provides its payment.
Once the payers handle their parts of the medical claim, the patient receives a bill from the provider for the rest of the medical costs.
Medicare.gov. “ Coordination of Benefits. “Accessed June 2022.
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Why Coordination Of Benefits Is Crucial
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Determining which insurance plan has the primary responsibility of payment when covered by multiple plans, explore why coordination of benefits is vital.
Did you know that the concept known as coordination of benefits (COB) allows you to maximize your health insurance coverage if you have access to more than one plan?
What Would Make Someone Subject to Coordination of Benefits Policies?
A married couple in which both spouses have coverage, a child has coverage available from both married parents, a child has divorced parents, both with coverage.
In this case, the child ordinarily would be covered by the custodial parent’s insurance. If that parent remarries, the step-parent’s plan might provide secondary coverage. The plan of the parent without custody typically pays last.
In a joint custody situation, the birthday rule usually applies. However, a divorce decree might influence which plan is primary.
If the decree states that one parent is financially responsible for the healthcare expenses of the child, then that parent’s plan would be primary for the child and the other parent’s secondary.
If the decree states that both parents are responsible, then their plans would be given the same priority and the determination would revert to the birthday rule described above.
A Child Has Their Own Policy But Also has Parental Coverage Through Age 26
A married child is continuing parental coverage through age 26, a child under age 26 with parental coverage is expecting a child, someone has workers’ compensation along with health insurance, someone has end-stage renal disease (esrd), someone has military coverage (tricare) or veterans administration (va) coverage along with other coverage, someone is eligible for medicare even though they’re still working, how to know what an insurer allows regarding coordination of benefits, what is coordination of benefits, leave a reply cancel reply.
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Coordination of Benefits (COB) applies when expenses for covered services are eligible under more than one insurance program. Usually, one health insurance company has primary responsibility and there is at least one other health insurance company with responsibility for any remaining patient liability. On occasion, an automobile insurance or workers' compensation insurance carrier will be involved.
Regardless of which insurance carriers are responsible, the combined payments are never greater than the actual charges of services and generally are not more than the primary carrier's contract rate. This portion of the manual offers some guidelines to help in COB situations.
Remember to ask your patient if they have other health insurance coverage.
Obligations of Physician to Obtain COB Information and to Bill Primary First
Claims should be submitted to the primary carrier first. You must help with processing forms required to pursue COB with other health care plans and coverages (including and without limitation, workers' compensation, duplicate coverage and personal injury liability). You are required to make diligent efforts to identify and collect information concerning other health care plans and coverages at the time of service. Where Horizon BCBSNJ is, or appears to be, secondary to another plan or coverage, you must first seek payment from such other plan or coverage according to the applicable rules for COB.
HCAPPA Revised COB Rules
The New Jersey state law known as the Health Claims Authorization, Processing and Payment Act (HCAPPA) states that no health insurer can deny a claim while seeking COB information unless good cause exists for the health insurer's belief that other coverage is available; for example, if the health insurer's records indicate that other insurance coverage exists. Horizon BCBSNJ will continue to gather information from members regarding other benefits in an effort to maintain accurate records and have the appropriate health insurer be financially responsible.
Patient Who has Two or More Insurance Plans (other than Medicare, Motor Vehicle Accidents or Workers' Compensation)
If you are providing care to the covered spouse of a Horizon BCBSNJ subscriber who also has his/her own health plan, the spouse's health plan is always primary UNLESS all of the following are true:
- The spouse is retired.
- The spouse is also eligible for Medicare.
- Our subscriber is covered as an active employee and Medicare is not primary under the Medicare Secondary Payer rules. In this event, the Horizon BCBSNJ coverage is primary, Medicare is secondary and the spouse's health plan is tertiary.
If you are providing care to a Horizon BCBSNJ subscriber who also has coverage as a subscriber with another health plan and the subscriber is:
- An active employee of one group and a retired employee of another. The plan from the group where the employee is active is primary.
- A retired employee of two groups. The plan in effect the longest is primary.
- An active employee of two groups. The plan in effect the longest is primary.
When providing care to a dependent child, whose parents are not separated or divorced and:
- The parents both have health insurance, determine from their benefit plans whether the Birthday Rule or the Gender Rule will apply. In most cases, the Birthday Rule will apply.
When providing care to a dependent child, whose parents are separated or divorced:
- The plan of the parent who has financial responsibility for health care expenses (as determined by the court) is the primary plan, regardless of who has custody of the child.
- For claims for a dependent child whose parents are separated or divorced, but a court has not stipulated financial responsibility, the unmarried parent who has custody is primary. The other parent is secondary.
- Any coverage through a stepparent married to the custodial parent would be next, and the noncustodial parent's coverage last.
BIRTHDAY RULE
Under the Birthday Rule, to determine the primary carrier, you need the month and day of the parents' birth dates; the year is never considered. The parent whose birthday falls earlier in the year has the primary plan for the dependent child. If both parents have the exact same birthday (month and day), the plan in effect the longest is primary. The Birthday Rule will only apply if both carriers use the Birthday Rule.
GENDER RULE
Under the Gender Rule, the father's plan is primary for the dependent child. If one parent's contract uses the Birthday Rule and the other contract uses the Gender Rule, then Gender Rule determines the father's plan as primary.
MOTOR VEHICLE ACCIDENTS
If the primary carrier is:
- The auto insurance, you must submit your claim to them. After you receive the Explanation of Payment (EOP) from the auto insurance carrier, send it to us with a completed claim form, an itemized bill and a copy of the member's Explanation of Benefits (EOB). Electronic claims cannot be accepted because of the additional information required to process the claim.
- If the primary carrier is Horizon BCBSNJ, we will need a copy of the automobile declaration sheet with the date of accident between the policy effective date and cancellation date. Be sure to attach an itemized bill and completed claim form.
Automobile insurance is not primary for motorcycle accidents for owner/operators of a motorcycle.
However, passengers of motorcycle accidents need to submit any accident-related claims to their auto insurance carrier for consideration.
WORKERS' COMPENSATION
Workers' compensation covers any injury which is the result of a work-related accident. Employers purchase insurance which covers work-related illnesses or injuries.
Horizon does not provide reimbursement for services rendered to treat work-related illnesses or injuries or for services or supplies which could have been covered by workers' compensation.
Always bill the workers' compensation carrier directly for work-related illnesses or injuries.
If Horizon Casualty Services, Inc. is the workers' compensation carrier, mail medical bills to:
REGULATIONS ON NEW JERSEY INSURED GROUP POLICY
Special rules apply for Coordination of Benefits (COB) where the Horizon policy is an insured group policy issued by Horizon 11:4-28.7, as amended effective January 1, 2003, provides for different COB rules (as to insured group policies issued in New Jersey) depending on what basis the primary and secondary plans pay and whether the physician is or is not in the network of either or both plans.
If Horizon BCBSNJ is the primary payer, these rules do not apply.
If the Horizon BCBSNJ insured group policy is secondary, and the physician or other health care professional is in Horizon BCBSNJ's network, these rules apply:
- Where both the primary and secondary plans pay on the basis of a contractual fee schedule and the physician is in the network of both plans, Horizon BCBSNJ pays the cost sharing of the covered person under the primary plan up to the amount Horizon BCBSNJ would have paid if primary, provided that the total amount paid to the physicians from the primary plan, HorizonJ, and the covered person does not exceed the contractual fee of the primary plan and provided that the covered person is not responsible for more than the cost sharing under our plan. (N.J.A.C. 11:4- 28.7(e)1.)
- Where the primary plan pays on the basis of Usual, Customary and Reasonable (UCR) and Horizon pays on the basis of a contractual fee schedule, the primary plan pays its benefits without regard to the other coverage and Horizon pays the difference between billed charges and the benefits paid by the primary plan up to the amount we would have paid if primary. Our payment is first applied to the covered person's cost sharing under the primary plan. The covered person is only liable for cost sharing under our plan if he/she has no liability for cost sharing under the primary plan and the total payments of the primary and our plan are less than billed charges. The covered person is not responsible for billed charges in excess of the amounts paid by the primary and secondary plans and cost sharing under either plan. The covered person can never be responsible for more than the cost sharing under the secondary plan. (N.J.A.C. 11:4-28.7(e)2.)
- Where the primary plan pays on the basis of a contractual fee schedule but the secondary pays on the basis of UCR, and the physician or other health care professional is in the network of the primary plan, the secondary plan pays any cost sharing of the covered person under the primary plan up to the amount the secondary would have paid if primary. (N.J.A.C. 11:4-28.7(e)3.)
- Where the primary plan is an HMO plan but the physician or other health care professional is out of network and services are not covered by the primary plan, Horizon BCBSNJ pays as if it were primary. (N.J.A.C. 11:4-28.7(e)4.)
- Where the primary plan pays capitation and Horizon BCBSNJ's plan is an HMO plan that pays on a contractual fee schedule and the physician or other health care professional is in the network of both plans, Horizon pays the cost sharing of the covered person under the primary plan up to the amount Horizon would have paid if primary. (N.J.A.C. 11:4-28.7(e)5.)
- Where the primary plan pays capitation, contractual fee schedule or UCR, and Horizon BCBSNJ's plan pays on a capitated basis, Horizon pays its capitation and the covered person has no responsibility for payment of any amount for eligible services. (N.J.A.C. 11:4-28.7(e)6.)
- Where the primary and Horizon's plan are both HMO plans and the physician or other health care professional is not in the primary plan's network, and the primary has no liability, Horizon pays as if primary. (N.J.A.C. 11:4-28.7(e)7.)
MEDICARE ELIGIBILITY
There may be instances when an individual who has coverage with us may also be entitled to Medicare coverage. This section will help you to determine which plan will pay as primary.
COB when Medicare is involved is usually called Medicare Secondary Payer (MSP). MSP does not apply to members who have individual contracts. Medicare is always primary for individual contract holders.
There are three ways a person can become eligible for Medicare:
- Attaining age 65
- Becoming disabled
- Having end-stage renal disease (ESRD)
Attaining Age 65
When individuals reach age 65 and have contributed enough working quarters into the Social Security system, they are entitled to Medicare Part A benefits at no cost. To receive Medicare Part B benefits, they must pay premiums through monthly deductions from their Social Security checks.
For individuals who have not contributed enough quarters in the Social Security system, there are two ways they may receive Medicare Part A benefits:
- Through a spouse who has contributed enough quarters to the Social Security system. This is identified by the letter B following the spouse's Medicare claim number on his or her Medicare ID card.
- Purchase Medicare Part A benefits. This is identified by the letter M following the Medicare claim number on his or her Medicare ID card.
Becoming Disabled
Disabled individuals under age 65 are entitled to Medicare under the disability provisions of the Social Security Act. They must be unable to work and must have been receiving Social Security disability payments for 24 months. Beginning with the first day of the 25th month of receiving Social Security payments, they are entitled to Medicare Part A benefits at no cost. Medicare Part B benefits may be purchased.
Having End-Stage Renal Disease (ESRD)
A person becomes eligible for Medicare under the ESRD provisions after beginning a regular course of renal dialysis. He/She is entitled to Medicare benefits after completing a three-month waiting period beginning the first day of the month after the start of a regular course of renal dialysis. The waiting period continues until the first day of the fourth month following the initiation of renal dialysis. On the first day of the fourth month, such a person is entitled to Medicare Part A at no cost.
Medicare Part B benefits may be purchased.
The three-month eligibility waiting period for ESRD Medicare benefits may not apply when the Medicare-eligible individual:
- Receives a kidney transplant. In this circumstance, the individual is entitled to Medicare the first day of the month in which the transplant occurred.
- Initiates a course of self-dialysis training during the three-month waiting period. In this circumstance, the individual becomes entitled to Medicare the first day of the month of his or her eligibility.
MEDICARE SECONDARY PAYER
There are three ways a Medicare-eligible person may be primary with us under an employer group health program:
- Working-aged
- End-stage renal disease (ESRD)
See chart on the next page for more detailed information.
Working-Aged
When a person becomes entitled to Medicare at age 65, there is the possibility that he or she has health insurance through an employer group health account. It is important to know whether the policyholder (subscriber) is retired or actively working.
To determine who is primary, three questions need to be asked of the Medicare beneficiary who has a group health policy through Horizon BCBSNJ:
- Are you or your spouse actively employed?
- Are there 20 or more employees (regardless if full-time or part-time employees) where you or your spouse work?
- Are you covered under that insurance policy?
If the answers to all three questions are YES, then the Horizon BCBSNJ group health policy would be primary to Medicare for the Medicare-eligible person.
Special Enrollment Period for Medicare Part B Benefits
A Medicare-eligible person may choose not to purchase Medicare Part B since it may not be necessary if the group is primary. When Medicare becomes primary, the subscriber may sign up for Medicare Part B benefits, with no increase in premiums. Coverage begins the first day of the month following the month the primary coverage ends. The person must sign up immediately upon becoming eligible once Medicare is primary, since the Medicare Part B benefits will only begin the first of the month that he/she signs up. This is called the Special Enrollment Period (SEP).
If an individual is entitled to Medicare because of age and is covered under the MSP provisions, he/she has the right to select Medicare as primary. If the person selects Medicare as primary, he/she must be dropped from his/her employer's group health benefits with the exception of prescription drug and dental coverage. The employer may not subsidize a supplemental Medicare plan under these circumstances.
If Medicare is primary and the subscriber chooses not to purchase Medicare Part B benefits, we will never pay more than we would have if that individual had Medicare Part B benefits. In addition, this person would not be eligible for the SEP and would face increased premiums and be restricted when he/she signs up for Medicare Part B benefits.
If you need help understanding if Medicare or a group health plan is primary, call the CMS Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627 .
* This does not apply if the member was Medicare-eligible due to age or disability prior to ESRD eligibility and the group health plan was primary due to other Medicare Secondary Payer rules. In this case, the group health plan would remain primary for the first 30 months of ESRD eligibility.
MEDICARE EXCEPTIONS
MSP regulations only apply when the insurance coverage is through an employer. A Medicare supplemental policy, or Medigap policy, may be offered by an employer (if there are less than 20 employees or if the employee is not actively working) or it may be purchased on an individual basis; however, a Medicare supplemental policy will never be primary over Medicare.
Medicare Part A
If there are no Medicare Part A benefits, MSP regulations do not apply. Medicare Part A services are billed to the group health plan.
Individuals who have purchased Medicare Part A benefits are identified with an M at the end of the Medicare claim number on their Medicare ID card.
Individuals entitled to Medicare due to disability must be under the age of 65, otherwise the working-aged provisions apply. You should ask the following questions to determine primacy:
- Are you, your spouse or a family member actively employed?
- Are there 100 or more employees (regardless if full-time or part-time) where you, your spouse or family member works?
- Are you covered by that insurance policy?
The two important differences between the MSP working-aged and the disability provisions are:
- Who the active employee is; and
- The number of employees in the group.
Unlike the working-aged provisions, under the MSP disability provision, the Medicare-eligible individual may be covered by a family member other than his/her spouse. This typically occurs when a parent or legal guardian covers a disabled dependent – either child or adult.
Under the disability provisions, the employer must employ 100 or more employees. It is important to verify the number of employees because the patient may be part of a subgroup within a group, such as the New Jersey State Health Benefits Program (SHBP) and School Employees' Health Benefits Program (SEHBP). There may be local municipalities with fewer than 100 employees, but the larger group has greater than 100 employees. The number of employees in the entire employer group is considered when making the determination of eligibility for Medicare due to disability.
- The patient is entitled to Medicare due to disability. He is not actively working, but his wife is and she has family health coverage through her employer, which has more than 100 employees. The patient would be primary under his wife's group health policy since she is actively employed by an employer of 100 or more employees and her group health insurance covers him.
- A patient is entitled to Medicare due to disability and is covered under his mother's insurance. She is actively employed and has family group health coverage through the employer who employs more than 100 individuals. In this case, the son's primary insurance is the mother's group health insurance plan.
- The patient is Medicare-eligible due to disability and is actively employed by a municipality that provides group health coverage. While she is no longer collecting Social Security disability payments, she still continues under the Medicare program. The municipality has only 35 employees but their health coverage is through the New Jersey State Health Benefits Program (SHBP) and School Employees' Health Benefits Program (SEHBP), and the state employs more than 100 individuals. The group health insurance would be primary for the patient and Medicare would be secondary.
- A local union may appear to employ fewer than 100 employees, however, the patient's coverage is through the Health and Welfare Fund for all union members. If just one of the local unions that belong to that Health and Welfare Fund has 100 or more employees, then any local union covered by the Health and Welfare Funds health plan would be covered by the MSP regulations.
End-Stage Renal Disease (ESRD)
A person becomes Medicare-eligible due to ESRD when he or she begins a regular course of renal dialysis. There is a three-month waiting period to receive Medicare Part A and Part B benefits (unless an exception applies).
When a person is entitled to Medicare due to ESRD, the MSP regulations will apply when:
- The patient has group health coverage of their own or through a family member (including spouse).
- That group health coverage is through a current or former employer.
When the Medicare beneficiary meets the above conditions, he/she is primary under the group health coverage for a specific period of time known as the Coordination of Benefit (COB) period. The COB period always begins on the first date of entitlement, and all medical services are covered by the group health coverage – not just renal services.
If the individual became entitled to Medicare due to ESRD, they have a 30-month COB period, beginning with the first date of entitlement.
- Medicare was already paying primary for a Medicare-eligible individual due to attaining age 65 or disability because they did not fall under either the Working-Aged or Disability provisions.
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