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Health Insurance Coordination of Benefits

Coordination of Benefits (COB) means where a person is covered under more than one insurance to cover the maximum benefits. Where one plan became the primary plan and pays benefits while the other plan act as a secondary plan that pays the balance expenses, subject to its plan benefits, network, and limitation.

How Coordination of Benefits Works?

When your family and friend are covered under more than one insurance plan, when you are under group insurance as well as spouse insurance plan, so here one plan will be considered as primary and the other one will be considered as the secondary plan.

The COB (Coordination of Benefits) policy will determine which plan should be considered as the primary plan and which one as secondary, and according to that the benefit will coordinate among the insurance plans, and also payment does not exceed 100% of the charge for the service.

Process Coordination of Benefits

  • Ensure that the claim is being paid correctly, and also consider which insurance will pay the first.
  • They Share medical eligibility data with other payers and also transfer the medical paid claim to the insurer for secondary payment.
  • Make sure the amount paid by the claim in dual coverage situation doesn’t exceed 100% of the total claim, avoid the duplicate claim.

Coordination of Benefits Data Sources

COB gets their data from many databases which are maintained by many state programs, federal which is included in stakeholders. Some of the ways through which COB collect information are below:

  1. COBA – COB Agreement program: The CMS consolidates the Medicare payment claim across over through the COBA program. The COBA program has many national standard contracts between other health insurance companies and BCRC. Which helps them to collect the data of paid claim data, etc.

 

  1. Voluntary data sharing agreement (VDSAs): This agreement helps the COB to get the information of insurance plan enrollment information electronically. For further information click the link: https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/EmployerServices/Voluntary-Data-Sharing-Agreement.

 

  1. Medicaid, Medicare, and SCHIP Extension Act of 2007(MMSEA) section 111: This section mandate for reporting the requirement of group health plan arrangement and for liability insurance, no-fault insurance, including self-insurance and workers compensation. An insurer is legally bonded to provide information.

When to Contact the BCRC

  1. To ask a general question of MSP.
  2. To report the worker’s compensation, auto/ no-fault, and liability.
  3. To report employment changes and any other insurance information.

Situations Where Coordination of Benefits is needed

Situations Where Coordination of Benefits is needed

Other Important Information

Some or partial cost of medical cost is taken care of by an insurance party other than:

  • A member who gets injured or become ill because of accidents or environment during work then he is eligible for benefits under the workers’ compensation law, if they deny all or partial then the claim will be reviewed to determine whether need to pay the benefits as the secondary plan.
  • Another insurance plan will not pay if the person is covered under the government scheme.
  • A person must follow the rule of a primary insurance plan to be considered in paying secondary.

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Written by Saakshi Gupta

Saakshi Gupta is a BBA LLB student at the Fairfield Institute of Management and Technology (GGSIPU), New Delhi. Her passion for law and business brought her to pursue law. She has a keen interest in business law, environmental law and also wants to explore more in the field of law. Apart from legal academia, she is a volunteer at a govt. program (National Service Scheme).

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