Dual Coverage
What Happens if you have two or more Insurance Policies at the same time?

Coordination of Benefits

Benefits When You Have Coverage under More than One Plan

When Coordination of Benefits Applies

This coordination of benefits (COB) provision applies when a person has health care coverage under more than one Plan

The order of benefit determination rules below govern the order in which each Plan will pay a claim for benefits.

The Plan that pays first is called the Primary Plan. The Primary Plan must pay benefits in accordance with its policy terms without regard to the possibility that another Plan may cover some expenses.

The Plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all Plans do not exceed 100% of the total Allowable Expense.  §1300.67.13 *   UHC EOC

References & Links

model laws 50 pages drafted by the National Association of Insurance Commissioners (NAIC)

Simple explanation of how Co Ordination of benefits works – Financial Web

Illinois.gov – Simple Explanation with charts

 

More Explanations of #COB Coordination of Benefits

Delta Dentals Explanation

“Working Spouse Rule”

Health Care Reform Dependent Coverage vs Spousal Coverage

How about an HSA (Health Savings Account) rather than buying extra policies?

There might be some cases where a COB provision is not allowed – like HIPAA policies for when COBRA ends.


Individual Plans
cannot  have this clause per CCR California Code of Regulations 1300.67.13 BUT, they might require that you cancel other coverage.  Blue Cross EOC Page 5

With COBRA protections and HIPAA availability when you lose Group Insurance, it probably is no longer necessary to keep an individual plan, “just in case.”  The extra premium, would probably be better spent on Life or Disability Insurance.

Life Insurance does not have a co-ordination of benefits clause.  They will ask on the application though if you have other coverage to prevent over insurance and to make sure there is insurable interest.

See also Balance Billing
What if your doctor charges more than the negotiated rate?

Technical Resources

Subrogation if you get in an accident and someone else can be sued

CA Insurance Code §10270.98  Group Health Insurance Co-Ordination of Benefits

Medicare Dual Coverage
# 02179
 
 

Medicare Dual Coverage Pamphlet

Our Webpage on Medicare & Dual Coverage 

Coordination of benefits -
two or more insurance plans
VIDEO 

Employer obligation to report # of employees to Medicare

Explanation from Cal Broker Magazine Sept 2019

Subrogation
Medicare's Right to collect from other Coverage

You're Medicare Advantage plan has  the right and responsibility to collect - subrogate  for covered Medicare services for which Medicare is not the primary payer.

According to CMS regulations at 42 CFR sections 422.108 and 423.462,    Anthem MediBlue Access (PPO), as a Medicare Advantage organization, will exercise the same rights of recovery  that the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any state laws.  Anthem MediBlue Access (PPO) Evidence of Coverage

Guide to #Contract Interpretation 

  • Read the Statute – Policy
  • Read the Statute – Policy
  • Read the Statute – Policy
  • Then when you think you understand it, read it again

guide to contract interpretation

Our webpage on

Get FREE Instant Individual & Family  California  Quotes - Including Tax Subsidy Calculation - Guaranteed Issue - No Pre-X Claus

Get FREE Instant Quotes - Including Tax Subsidy Calculation - Guaranteed Issue - No Pre-X Clause

Full Instructions to use Individual Quote Engine

how to get quote - full instructions video by steve

eoc.complaints
Specimen EOC Evidence of Coverage – Appeals – Grievances

Child Pages

Get Instant Term Life Quote

get term life quotes

Life Insurance Buyers Guide

NAIC Life Insurance Buyers Guide

How much  life insurance you really need?

Video Insurance Unnecessary Cost?

36 comments on “Dual Coverage – Who pays 1st? Collect Twice? Individual Plans

  1. Primary vs Secondary in emergency

    We cover adult employed daughter under age 26- she received coverage from her new employer November 1.

    On November 14 she was in a bad accident and required emergency care. She gave her Blue Shield information. Her injury and subsequent care have been extensive including emergency spinal surgery in December.

    We just received notice from Blue Shield that effective November 1 Kaiser was primary and should be paying the costs.

    What are our rights in this case?

    The notices from Blue Shield are addressed to us as she is the dependent.

    • We need to see the letter you got from Blue Shield. We are not allowed to accept hearsay.

      M. “Primary plan” means a plan whose benefits for a person’s health care coverage must be determined without taking the existence of any other plan into consideration. A plan is a primary plan if:

      (1) The plan either has no order of benefit determination rules, or its rules differ from those permitted by this regulation; or
      (2) All plans that cover the person use the order of benefit determination rules required by this
      regulation, and under those rules the plan determines its benefits first. NAIC Model Rules

      So, if you don’t go to Kaiser they won’t pay. Thus, Blue Shield will pay at a non kaiser facility.

      Do NOT take this answer to the bank. We need the letter and your EOC’s Evidence of Coverage. If you don’t have ready access to your EOC, give us the exact name of your plan, we probably have access to them.

      FYI, Medi Cal doesn’t allow one to get an HMO if other coverage is available!

      Kaiser Group Information

      Blue Shield Individual & Family Information

      Our webpage on reading Insurance Policies and the Law – Read 3 times, then when you think you understand it, read again.

      • Thanks for your response!

        The letter that my husband received from Blue Shield, after looking more carefully this morning, are actually copies for his information that were sent to the health care facilities and the hospital where she was taken. The letters tell the facilities that they should be billing Kaiser.

        If you’d like a copy to see what it says, please let me know how to get it to you, or if you’d just like the transcript here.

        Also, the coverage we have had for a few decades is Blue Shield of CA, HMO.

        • My email is encrypted coming and going by http://www.Paubox.com or you can upload to https://www.paubox.com/steveshorr/upload

          I need an EXACT name of the plan that you have with Blue Shield and your daughter has with Kaiser. If it’s an individual plan, it might not be allowed to have a co-ordination of benefits clause, see webpage above for citation.

          Since your daughter was in the hospital for an emergency, Kaiser would probably have to pay for it, even if not in their facility.

          Please advise exact name of plan. The EOC is 10 times easier to review, than trying to piece together all of the various laws and statutes.

          • I just sent a copy of the letter to the link you provided. And the name of the insurance we carry is Blue Shield HMO, Pomona Valley Medical Group Inc. DBA, Pro Med Health Network A+… Does that help?

            • No, I need the exact name of the plan or your EOC. Please visit the links above for our Group and Individual Blue Cross pages. It’s my understanding from above that there is no co-ordination of benefits on an individual plan.

              Rather than spend hours researching the law, pro bono, the answer is in your EOC.

              How about sending a copy of your ID card?

              • This is just a routine letter from Blue Shield letting the hospital know that under the rules for Coordination of benefits, Kaiser is supposed to pay first. If there is any portion of the bill that Kaiser doesn’t pay, then Blue Shield will pay up to their limits. It looks all routine to me.

                I believe your concern is that you think that Blue Shield is saying you HAVE TO GO TO KAISER and not Blue Shield. There is nothing in the letter that says that.

                I’m sure if you send me the EOC’s there is nothing there that says that.

                Go to whatever MD you want, as long as they are on Blue Shields or Kaiser’s list.

                • It seems to be quite tricky to actually FIND our EOC docs! My husband has sent and email to his HR department because the Blue Shield member page tells us “we may not be able to access” all the documents, and it seems the EOC is one of them? Is there a way around this if his HR department doesn’t come through?

                  • Go to our Blue Shield Employer Plan administrative Webpage

                    Then click on the forms image
                    forms

                    Watch Loom Video for more details

                    No one is telling you that your daughter must go to Kaiser, right? So, why worry? What difference does it make which plan pays first for the emergency care? The 2nd plan will pay after the first one does.

                    Normally, we do NOT deal with 3rd parties for competent adults. If you are going to ask more questions, we need you to “certify” that your daughter is too severely injured to handle this on her own.

                    Here’s where we enrolled a woman in Covered CA who had been in a major accident with her parents. When she got better we were accused of Fraud, etc. as she qualified for Medi Cal. Comment 1 ** 2

          • Forgot to add… we literally have no record of the Kaiser plan. It was provide through a small organization in northern California called Animal Place. I believe it’s small group insurance in that case. Nothing fancy…

          • I just sent the Blue Shield EOC.
            Please advise on where to look for information related to this case.
            Thanks so much!

  2. This is a cut and paste from a prior Q & A to consolidate our website

    What are the rules with dual coverage in regards to
    COBRA for the husband & a group plan for wife?

    The Primary (person A)

    ***[How do I know, who is primary? I need to see the documents]

    If you are covered as an employee, member or subscriber under more than one plan, but are covered under state or federal continuation (COBRA) under one of the plans, then:

    The plan covering you as an employee, member or subscriber is primary over the plan covering you under state or federal continuation (COBRA). illinois.gov

    has health insurance through their job, loses job, continues COBRA coverage for the family, meets the maximum deductible of $4000, [individual and/or family deductible] they have 0% out of pocket expenses now except for the monthly premium of $1,442.

    Mid-year the spouse (person B) now gets a job with health insurance coverage through their employer.

    The premium is much less $338, deductible of $3,000 with 80% coverage for in-network.

    If they cancel the COBRA, then they pay a new deductible +20% of medical charges incurred. If they overlap and have dual-coverage, then they are really paying extra money for the second medical plan $338/month with little benefit

    ***I don’t quite follow, sounds like more benefit

    -since they’ve met their deductible and pay 0% out of pocket.

    What if the family has dual coverage for 1 month, then after the second month they cancel COBRA?

    Do they still have to meet the new deductible of $3,000?

    ***I’d have to see the new policy. I doubt there is any take over provision.  Thus, yes.

    Does the insurance company only look at charges that have occurred within that month of dual coverage in order to determine if deductible B $3,000 has been met?

    ***Deciding what medical bills go to the deductible has nothing to do with having other coverage.

    How do they determine when it’s beneficial to have dual coverage?

    ***The Insurance Company doesn’t decide if it’s better for you. That’s your decision. Why pay $1,442 to have dual coverage? In two months, you have the $3k deductible taken care of.  Also, the $338 contribution as the employer is paying the rest of the premium, is probably tax deductible, if the employer has set up a Section 125 POP Plan.

  3. This is a cut & paste of a question we had on another page. We are putting it here, to better consolidate our website and put everything in a more logical order.

    The links and formatting get lost in the cut and paste. Just use our search engine at the top, when you need more detail on any of the technical terms.

    I have pretty good Cobra Insurance (Health Net PPO, eligibility expires 12/17), however, I am concerned with the current political climate, Obama Care may go away

    ***Here’s where I’m keeping up on the status. donaldcare.healthreformquotes.com

    and when I am no longer eligible for Cobra, it might be difficult to get insurance due to pre-existing condition or other medical related risk factors becoming a factor as they were in the past. To protect against that, I would like to get a Blue Cross PPO now

    ***Click here to get proposals, benefits, subsidy calculation etc. http://www.quotit.net/eproIFP/webPages/infoEntry/InfoEntryZip.asp?license_no=0596610

    In the past we had HIPAA for those who lost COBRA. There was also MR. MIP – High Risk Pools.

    and just continue it until my Cobra expires.

    ***Losing COBRA gives you a Special Enrollment Period

    So therefore, I would have two health plans. My current Cobra group plan and an individual/family Blue Cross PPO plan.

    The questions I have are:

    Can I have two health plans (I’m not trying to commit fraud, I understand I cannot get paid more than the bill).
    Dual Coverage & Co-ordination Rules

    Let’s see if the question is asked on the paper application – I’m looking at doing this direct, no Covered CA no subsidies. For subsidies, the answer would definately be NO.

    Question G 2 asks about other coverage and if you plan to cancel it. So yes, you would have to disclose other coverage. I doubt they would write you. If it’s that important to you I could email them and ask. I could also check the ACA rules and see if the ACA law says you can buy coverage, even if you have other coverage.

    Do I need to tell Blue Cross?
    Yes, since they ask.

    Can I pick and choose who I want to use, if Blue Cross

    Please get a quote proposals, benefits, subsidy calculation. I don’t think Blue Cross has a PPO in your area. Try Blue Shield.

    has a doctor I like or pays more benefits for a particular procedure, can I only use them.

    These questions are quite complex and I think I’m going to have to charge a research fee for them. Under ACA, I practically have to work for free.

    See our page on Dual Coverage, see also the rules in the current evidence of coverage, if we can even get you an extra policy, that we do NOT recommend that you purchase!

    The same for Health Net PPO, use them if they are more beneficial for the procedure I have. – Please answer for Blue Cross, I have already got Health Net’s comment.
    Verbal comments are worthless!!!

    See the rules on dual coverage, basically the 2nd company pays up to 100% of what the first one didn’t. It may well be that there is NO co-ordination of benefits clause on two INDIVIDUAL policies. Thus, you could collect more than 100%, which is why I don’t think you will get a policy issued, if you plan to keep the first one.

    Note too, that I won’t give an answer, unless I can show it too you in writing or the law. I don’t want to have to pay the claim out of my pocket.

    My intent it to cancel my Health Net policy down the road

    I think you should keep it, till you really want to move and it expires. There is also Cal COBRA, which gives you another 18 months of coverage.
    but I have had it for 15 years and am leery just to let it go.
    Also, I go to doctors who do not take insurance. Can I go to doctors who do not take insurance and not let Blue Cross know I am having a procedure done?

    If you have a PPO, you could still turn in the claim. When a MD says they don’t take insurance, that just means they don’t agree to the negotiated rate, they still will cash the check.
    Usually the bills are below the deductible or I don’t want to wait for an approval – like an MRI)

    The question is beyond my pay grade.

  4. I worked at a company that paid fully for our health benefits. I quit, but they didn’t take me off their coverage for 6 months. They prior insurance company still paid for my Rx Prescriptions.

    One of the medications that was claimed with my old insurance needed a prior authorization in order to fulfill. Since my new insurance won’t cover it who is liable?

    Will the ACA clause regarding recession of coverage protect me from having to pay?

    • IRS Instructions to Form 8962, “Coverage in the individual market outside the Marketplace. While coverage purchased in the individual market outside the Marketplace is minimum essential coverage, eligibility for this type of coverage does not prevent you from being eligible for the PTC for Marketplace coverage. Coverage purchased in the individual market outside the Marketplace does not qualify for the PTC.”

      While it looks like rules allow people to have both on on-exchange and off-exchange health plans, and receive the APTC, I don’t think people should expect the health plans to completely cover any health care claim twice.

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