Health Care Benefits: Coordination of Benefits
You and your family members may have coverage under more than one health plan. The health plans include a coordination of benefits (COB) provision to eliminate duplication of payment for services. However, there is no COB for prescription medications.
- Under COB, the plan that pays first is the primary plan.
- The secondary plan pays after the primary plan.
- The result is that both the state and the other insurance company pay a fair share but the combined payments by both plans will not exceed the maximum allowable reimbursement.
How COB Works
If you have coverage under more than one plan, you have a responsibility to help make COB work for you. When you incur charges, you need to submit all bills to the carrier you believe to be primary and write the name of the other carrier on the claim form. The carriers will make determinations about which is primary and which is secondary.
There is no coordination against the following kinds of coverage:
- Group hospital indemnity coverage that pays less than $100 per day
- Individual (not group) policies or contracts
- Medicaid
- School accident coverage
- Some supplemental sickness and accident policies
Determining Who Is Primary
To decide which health care plan is primary, your health plan has to consider both the coordination of benefits provisions of the other health care plan and which member of your family is involved in the claim. The primary health care plan will be determined by rules established by the plan:
Your Health Plan as Primary
Your plan will pay the full benefit provided by your contract as if you had no other coverage.
Your Health Plan as Secondary
When your plan is the secondary plan it will make payments based on the balance left, if any, after the primary health care plan has paid. Your plan will pay no more than that balance up to the amount it would have paid had it been primary. In some cases, this may be nothing at all.
Your plan will pay only for health care services that are covered under this contract and will pay no more than the “allowable expense” for the health care involved.
If You Have a COB Dispute
If you believe that a claim was not paid properly because of COB, you should first attempt to resolve the problem by contacting your health plan. If you still are dissatisfied, and would like instructions on filing a consumer complaint, you may call the Ohio Department of Insurance at (614) 644-2673 or (800) 686-1526.
Enforcement of Provisions
Your health plan will coordinate your benefits, if you properly inform them of your coverage under any other health care plan. Your plan is required to determine if and to what extent you are covered under any other health care plan.
Through the utilization of your health care benefits, you and/or your dependent will be required to provide any requested information to your health plan to process the claim that has been incurred. Your health plan also may release or obtain necessary information without consent from your dependent.”
Facility of Payment
Your health plan will not pay a provider bill that has already been paid by the other health care plan. If payment that should have been made by your plan is made under any other health care plan, your plan will pay whoever paid under the other health care plan. Your health plan will determine the necessary amount under the provision, and any amount paid by your plan in this circumstance is considered a benefit under the plan. Your plan is discharged from liability to the extent of such amounts paid for covered services.
Your Health Plan’s Right of Recovery
If your plan pays more for covered services than this provision requires, it has the right to recover the excess from anyone to or for whom the payment was made. You agree to do whatever is necessary to secure your health plan’s right to recover excess payment.
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