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)

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

  1. 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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