What Is Coordination of Benefits?

What Is Coordination of Benefits?

When you need care and are on two different health insurance plans, your insurers will coordinate your benefits to give you maximum coverage when you need it.

If you are covered by two different health plans, your provider may file the claim with both plans. Then the health insurers will decide which plan covers which expenses on the claim. This is called Coordination of Benefits. If there are instances where you need more benefits to cover your health expenses than your primary plan covers, the secondary plan may pay part of a claim or an additional amount toward the claim, based on its coordination of benefits rules.

How It Works

Here are some examples of when coordination of benefits is needed:

  • You are on your employer's health plan and you are also on the plan your spouse has with their employer.
  • You purchase your own health plan, but you are also on your spouse's group plan.
  • You and your spouse both have individual policies and are listed as dependents on both.
  • If you have dependent children covered under both your and your spouse's health plan
  • In the case of a custody agreement, one parent may be required to cover the children but both parents choose to include them on their coverage.

Note: If you have Medicare and another plan, coordination of benefits is always used. Medicare may be either primary or secondary based on the Medicare coordination of benefits. Letting your insurer know you have Medicare up front will save you and your doctor time when it comes to filing claims.

Why Coordination of Benefits?

Coordination of benefits helps:

  • Avoid duplicate payments by making sure the two plans don’t pay more than the total amount of the claim.
  • Ensure the appropriate payments are made by each plan.
  • Reduce the cost of insurance premiums.

At times, you may get a form in the mail, an email or a call from your insurer to set up the coordination of benefits so claims get paid correctly. You may also want to document any other coverage   you have when your plan renews each year.

Even if you don’t have other coverage, you will need to let your insurer know. Sometimes claims will be held until coordination of benefits is confirmed. That means the provider won’t be paid until primary and secondary coverage is confirmed.

Want To Know More?

If you have more than one health plan, check out the section of your benefit materials called Coordination of Benefits (COB) to learn how it works.

For more information, call the customer service number listed on your health plan's member ID card.

Source: Coordination of Benefits,   Centers for Medicare and Medicaid Services, 2020; How Medicare works with other insurance,   medicare.gov

Originally published November 23, 2020; Revised 2021

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