If you have two or more health insurance policies in force (dual coverage – secondary insurance) – which one pays 1st?
Co-ordination of Benefits(COB)?

The best most authoritative answer will be in the Evidences of Coverage (EOC).   Here’s an excerpt from a employer Group  United Health Care policy.   Request an EOC from YOUR insurance Agent or HR Department.  See below for other links and official brochures.

Generally, Individual Policies do NOT have a Co-Ordination of Benefits Clause.  Blue Cross PPO has one, ONLY if you have another Blue Cross policy.  Page 142 Specimen Policy   On the other hand, when you apply, the Insurance Company, might ask if you have other coverage.  In Group Policies are COB clauses are permitted, but cannot co-ordinate against Individual Policies. CA Code 10270.98

How about having just ONE policy and putting the premium savings into Life Insurance, Long Term Care or an IRA?

Brochures, Links & Resources with the EXACT answers!

Medicare Guide to who pays first # 02179

Medicare Guide to who pays first # 02179

 NAIC Summary on Co-Ordination of Benefits

NAIC Summary on Co-Ordination of Benefits

Employer Health Policy - Specimen - COB Rules

Employer Health Policy – Specimen – COB Rules

  

 

Get Instant Individual & Family Quotes including Subsidy Calculation
Get Instant Individual & Family Quotes including Subsidy Calculation

 

Travel Insurance - Your California coverage might not cover outside USA
Travel Insurance Quotes & Enrollment– Your California coverage might not cover outside USA

 

 

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

Illinois.gov – Simple Explanation with charts

Medicare

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  *

Medi-Cal

Medi Cal, Medicare & Private Insurance pdf

Cal Duals – Medicare & Medi-Cal together

Medi-Cal & Other Coverage

Other

Delta Dentals Explanation

California Code of Regulations    1300.67.13

“Working Spouse Rule”

Health Care Reform Dependent Coverage vs Spousal Coverage

National Association of Insurance Commissioners – Model Regulation 64 pages

One page summary 

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?

Child Pages

Click here for our Instant Quote Engine

Technical Resources

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

 

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

 

Except as permitted by this section and by Section 10323, 10369.5, 10369.6, or 11515.5,  Chapter 11A  29 U.S.C. Sec.  186),  regulations adopted by the Director of the Department of Managed Health Care

TITLE 28. 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)

Historical Info

Can a husband & wife have coverage from each of their employers?

What if you are divorced?

If they have coverage from one employer, can the other one refuse coverage through their work?

It is not generally up to you to decide which policy pays 1st.  The rules under most circumstances are below. Why not just turn in the claim to all relevant policies and let them sort it out?

How about having just ONE policy and putting the premium savings into Life Insurance, Long Term Care or an IRA?

What are the co pays?
Can you collect more than your actual medical expenses?

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

    • 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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