How to talk to your patients about Coordination of Benefits

Coordination of Benefits (COB) is the process used to determine the primary and secondary plan when a member has more than one health plan. The many rules can be a bit confusing, so here are 4 things your patients should know about COB. For more detailed information, see our COB post for providers.

1. Subscriber vs. Dependent: If a member is the subscriber (owner) of an employer group health plan, then that plan will be their primary plan. This plan will also be the primary plan for the whole family unless the subscriber’s spouse carries an employer group plan under their own name. 

If the spouse does carry an employer group plan under their own name, then that plan is their primary plan. So, each spouse has their own primary plan through their respective employers while, at the same time, they are dependents under each other’s plan. 

Example: John subscribes to NHP through his employer. At the same time, John’s wife Mary subscribes to BCBS through her employer. John’s primary plan is Neighborhood Health Plan while his secondary plan is BCBS. Mary’s primary plan is BCBS while her secondary plan is Neighborhood Health Plan. 
 
2. Birthday Rule: This rule comes into play when members have a child who has health insurance under both parents. (Remember John and Mary above.) COB rules for the child are determined by the parents’ birthdays. The parent whose birthday comes first in the year provides the primary coverage.
 
Example: (Using John and Mary again) If John was born on May 11 and Mary was born on September 23, then John’s plan is the primary plan because his birthday comes first. If both spouses have the same exact birthday, whichever policy has been active longer is the primary plan. 
 
3. Cost Sharing: Many patients may assume that because they have two plans, they will not be responsible for any copayments or other cost sharing. This might not always be the case. Cost sharing can apply even after both carriers have paid the claim because each plan has its own benefits and cost sharing. Just because the primary plan pays first, and cost share is applied, doesn’t mean the secondary plan doesn’t have its own cost share, as well. 
 
4. Secondary Claims Payment: For claims to be processed correctly, your provider should always submit an Explanation of Payment (EOP) from the first payor when sending the claim to the secondary payor. If a member hasn’t informed the provider of another possible payor, then all the benefits available to the member are not being utilized. This may impede the provider from getting paid the full amount due, as well as cause the member to be responsible for cost share that could have been applied to the secondary payor. 
 
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