Understanding Coordination Of Benefits

When your employees or their dependents have other health care coverage in addition to a Regence BlueCross BlueShield of Utah Plan, payments for hospitals, physicians, and other services will be determined by coordinating the benefits of the two programs. Under coordination of benefits (COB) clauses in health care contracts, carriers agree to work together to protect your investment in health care by preventing duplicate payments.

For fully insured groups with employees having dual coverage, they will receive the maximum benefit to which they are entitled. We use Utah Insurance Department guidelines to determine which company pays first on a claim. According to the state’s coordination of benefits policy, the primary carrier pays the full benefits available under its program, and the secondary carrier pays the balance of covered expenses not to exceed the least of:

• Copay and deductible owed by the member under the primary plan, if either carrier has contracted for discounted provider fees; or
• The highest allowable expenses under any of the plans, if none of the plans has contracted for discounted provider fees; or
• The amount the secondary plan would have paid in the absence of the primary plan.

Guidelines are subject to change as a result of state or federal regulations.

To protect your premium, we need information about any other group health care coverage your employees have. This information is requested on the application for group coverage. Also, when we receive a claim that may require coordination, we periodically request information regarding any additional coverage.

When there is other health care coverage, primary and secondary carrier status is determined according to the first of the following rules to apply:

1. If another plan does not contain a coordination of benefits provision like this one, the other plan has primary responsibility.
   
2. A plan that covers the person to whom the claim relates as other than a dependent has primary responsibility over a plan covering the person as a dependent.
3. If the claim is for a dependent child and the child’s parents are married or living together, the benefits of the plan of the parent whose birthday falls earlier in the calendar year pay first. If both parents have the same birthday, the benefits of the plan that has covered one parent longer are paid before those of the plan that has covered the other parent for a shorter period. If one plan has a different rule regarding coverage of a dependent child and that rule would provide a different result than this one, that other rule should be followed.
4. If the claim is for a dependent child of parents who are divorced, separated or not living together, the plan that covers the child as a dependent of the custodial parent has primary responsibility. If the custodial parent has remarried, the plan that covers the child as a dependent of the custodial parent’s new spouse is primary to the plan of the noncustodial parent. If there is a court decree that establishes financial responsibility for a dependent child’s health care or health coverage expenses, the plan that covers the child as a dependent of the parent with such financial responsibility pays first regardless of the above rules based on custodial status. If the parent with financial responsibility has no coverage but his or her spouse does, that spouse’s coverage pays first. If there is a court decree giving the parents joint custody without establishing financial responsibility for the child’s health care or health coverage expenses and the child’s residency is split between the parents, the rules for children of parents who are not divorced or separated as explained in 3) above shall apply to determine which parent’s plan is primary.
5. A plan that covers the person to whom the claim relates as an active employee is primary to a plan that covers that person as a laid-off or retired employee. If one plan does not contain this rule, however, this rule is disregarded.
6. If the order of responsibility cannot be determined by the above rules (such as when the same individual is covered by two group health insurance plans), the benefits of the plan that has covered the person to whom the claim relates for the longer period of time pays first. For purposes of this rule, two plans are treated as one if the person was eligible under the second within 24 hours after the first ended.

Benefits are also coordinated or otherwise affected by Medicare, Automobile No-Fault Insurance, Workers Compensation Law and/or Employer’s Liability Laws.

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