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. Plan is defined here.

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.  Read the rest the 7 page explanation

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

 

Brochures & Information on how  
Medicare Co-ordinates 

Medicare Guide to Rx Coverage Publication 11109 See Section 4

Our website on Medicare Rx Drugs

Medicare Website 

Publication 02179 Guide to who pays first

Our webpage on Medicare dual coverage

Medicare Coordination of Benefits Agreement Index    Coordination of Benefits Agreement    CMS.Gov

More Explanations of COB 

Delta Dentals Explanation

California Code of Regulations    1300.67.13

“Working Spouse Rule”

Health Care Reform Dependent Coverage vs Spousal Coverage

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

Supplemental Plans, like Colonial & AFLAC

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 §1300.67.13 b 2 d  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

regulations

Department of Managed Health Care

s 1300.67.13. Coordination of Benefits ( “COB”). section 10270.97 of the Insurance Code
Medi-Ca“Medicare”  a court decree  Section 10270.98, Insurance Code.
Health & Safety Code 1374.19. (a)

Child Pages

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19 comments on “Dual Coverage – Who pays 1st? Collect Twice?

  1. 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.

  2. 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.

  3. 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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