Coordination of Benefits Workshop November 10, 2014 Joint Health - - PowerPoint PPT Presentation

Coordination of Benefits Workshop

November 10, 2014

Joint Health Management Board

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What is Coordination of Benefits (COB)?

• It’s a way of coordinating benefits when you are covered by

more than one health plan.

• Both plans review and consider your claims.
• The plans coordinate to make sure you receive the

maximum benefits under both plans.

• COB helps lower your out-of-pocket costs.
• Coordinating benefits is one of the ways to keep employee

contributions at a minimum.

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Types of COB

• Internal “Cross Coverage” or “Dual Coverage”

– The FUSD Employee/Retiree is covered under the District Plan as both an Employee/Retiree and as a Dependent Spouse/Domestic Partner of another FUSD Employee/Retiree. – The Dependent Children of Dual Covered FUSD Employees are covered under both Employees/Spouses.

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Types of COB Continued

• External “Dual Coverage”

– A FUSD Employee, Retiree, or Dependent is covered under the District Plan and also covered under another health plan.

• Medicare

– A FUSD Retiree is covered under the District Retiree Plan and also covered under Medicare.

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How Does COB Work?

• Most plans use the primary-secondary rule

One plan is determined to be the primary plan and the other plan becomes the secondary plan

• The primary plan has the initial responsibility to consider

benefits for payment of covered services and pays the same amount of benefits it would normally pay, as if you didn’t have another plan.

• The secondary plan then considers the balances after the

primary plan has made their payment. This additional payment may be subject to deductibles, copays, and contractual limitations of the secondary plan.

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Primary versus Secondary

• The plan that covers the person as the Subscriber (not a

Dependent) is the plan that pays first. This is the “primary” plan.

• The plan that covers the person as a Dependent is the plan that

pays second. This is the “secondary” plan.

• If the person is a Dependent child, the ‘birthday rule’ is applied. The

primary plan is the plan of the parent whose birthdate occurs earlier in a calendar year.

• Regarding Medicare, Medicare is Primary, unless the person is

covered under an active group health plan (not a retiree plan).

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Effects on Coverage

• If a person covered under the FUSD Plan is also covered under

another health plan, total payment under the FUSD Plan and all

• ther plans combined will not exceed 100% of the allowable

expenses.

• For internal cross/dual covered members, the FUSD Plan will pay

up to 100% of the total allowable expenses after all applicable co- pays and deductibles.

• If the FUSD Plan is the secondary plan, any unpaid balance is

usually paid to the limit of the Plan’s responsibility and will not exceed the amount it would have paid had it been the primary plan.

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Other Types of Coordination Often, some or all of the costs of medical care are the responsibility of an insurance party other than the District Plan

• Members who are injured or become ill as a result of work-

related accidents are eligible for benefits under the Workers’ Compensation Law.

• Members who are injured by the act or omission of another

person/party. The other party may be liable or legally responsible for payment of charges incurred

– If the member has a claim against the other person, the FUSD Plan will be secondary and the Plan will be Subrogated and entitled to reimbursement.

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Effects of Medicare

• Medicare may be a participant’s primary or secondary coverage.

FUSD will coordinate benefits with Medicare according to the Medicare Secondary Payer rules.

• All FUSD Retirees eligible for Medicare Parts A & B should

enroll in Medicare Part A and Part B as their primary coverage. FUSD will pay as secondary regardless if Retiree enrolls in Medicare or not.

• When FUSD is secondary, the participant still needs to pay

applicable Plan deductibles.

• If Medicare does not cover a particular service, FUSD will pay

as primary. However, Medicare first needs to deny the service before FUSD will consider it.

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Other Coverage Is an HMO

• Typically, HMOs do not coordinate with other health plans.
• If a FUSD member is covered as a Dependent under a Spouse’s

HMO, and uses the services of that HMO, the FUSD Plan’s liability will be limited to the Copayments, Deductible, and Coinsurance required under that HMO (but not to exceed any benefits that would have been payable by the Plan).

• If the Spouse of a FUSD employee is covered under his or her own

HMO, that HMO Plan will be considered primary for the Spouse and the FUSD Plan will only reimburse Copayments, Deductibles, and any Coinsurance required under the HMO (but not to exceed any benefits that would have been payable by the Plan).

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• Contact Delta Health Systems Customer Service so they can

update their records. – When you or your dependents are covered under another plan. – When the other coverage cancels or changes. – When you successfully enroll in Medicare.

• Periodically, Delta will send you a routine questionnaire asking

about other coverage. – Complete and return the form promptly to ensure claims are processed timely and accurately. What if I Have Other Coverage?

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DHS COB Questionnaire

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What if I Have Other Coverage? Be sure that your providers have information for both plans. – Providers should submit your claim to the primary plan first. Once the claim has been processed and they receive an Explanation of Benefits detailing how the claim was processed, the provider should submit the claim to the secondary plan for consideration of the balances. – For cases of internal cross/dual coverage, the provider does not need to resubmit the claim to Delta.

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The majority of FUSD Plan coverages can be coordinated with

• ther plans

FUSD Plan coverages with COB

• Medical: Delta Health Systems and Kaiser Permanente

– Kaiser Permanente is a HMO Plan and does not coordinate with non-Kaiser plans. However, if you are double-covered through Kaiser, services are covered at 100%. – Double-coverage is not allowed through Senior Advantage (retirees).

• Prescription Drug: Prescription drug coverage through Citizens Rx

– Prescription drug coverage through EnvisionRx Plus is not eligible for Coordination of Benefits. – It is the members responsibility to submit a claim to Citizens for secondary consideration. This is a Direct Member Reimbursement

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The majority of FUSD Plan coverages can be coordinated with

• ther plans

FUSD Plan coverages with COB

• Behavioral Health: Mental Health and Substance Abuse services

through Avante Health

• Chiropractic/Acupuncture: Chiropractic and Acupuncture

coverage through ChiroMetrics

• Vision: Vision coverage through Medical Eye Services

– If you wear glasses, MES suggests you use the plans independent of each other. Instead, get two pair of glasses, one through each plan.

• Dental: Dental Coverage through Delta Dental PPO Plan

– Dental coverage through United HealthCare/Pacific Union Dental is not eligible for Coordination of Benefits

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Who to Contact

• Delta Health Systems

800-807-0820

• Kaiser Permanente

800-464-4000

• Avante Health

800-498-9055

• Delta Dental PPO Plan

888-335-8227

• Pacific Union Dental Napa Plan

800-999-3367

• ChiroMetrics

559-447-3375

• Citizens Rx

877-532-7912

• Medical Eye Services

800-877-6372

• District’s Benefit Department

559-457-3520

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Things to keep in mind Claim examples

• These examples are not meant to guarantee how a claim may
• coordinate. Each claim is different. Provider status, provider billing

practices, type of claim, type of service, internal or external plans,

• etc. all effect coordination.
• These are just a few examples, we could not cover each scenario in

this Workshop.

• Use of out-of-network providers will effect patient responsibility.
• ‘Plan A to B’ and ‘Plan B to A’ coordinate the same way. Remember

each Plan will only pay up to what it would normally pay.

• The following are a few examples of claim scenarios. Note, we could

not include every situation, but these should give you an idea.

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Claim Example 1

Internal Dual Coverage

Plan A. Office visit. Network Plan A. Office visit. Network

• provider. Deductible not met.
• provider. Deductible not met.

Primary Account: Secondary Account: Allowable $50.00 Allowable $50.00 Patient Co-Pay $15.00 Patient Co-Pay $15.00 Balance to Deductible $35.00 Balance to Deductible $35.00 Plan Pays $0.00 Plan Pays $0.00 Patient Responsibility $50.00* Patient Pays $50.00* Total owed to provider is $50.00, paid my patient. *Member should not pay provider until they receive secondary Explanation of

• Benefits. Final patient responsibility/pays is $50.00.

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Claim Example 2

Internal Dual Coverage

Plan A. Office visit. Network Plan A. Office visit. Network

• provider. Deductible met.
• provider. Deductible met.

Primary Account: Secondary Account: Allowable $50.00 Allowable $50.00 Patient Co-Pay $15.00 Patient Co-Pay $15.00 Plan Pays $35.00 COB/Primary Applied $35.00 Patient Responsibility $15.00* Plan Pays $15.00 Patient Pays $0.00* Total owed to provider is $50.00, all paid by Plan. Because the balance after primary account was only $15.00, the secondary account will pay up to that amount. *Member should not pay provider until they receive secondary Explanation of

• Benefits. Final patient responsibility/paid is $0.00.

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Claim Example 3

Internal Dual Coverage

Plan A. Office visit with procedure. Plan A. Office visit with procedure. Network provider. Deductible not met. Network provider. Deductible not met. Primary Account: Secondary Account: Allowable $300.00 Allowable $300.00 Patient Co-Pay $15.00 Patient Co-Pay $15.00 Deductible $250.00 Deductible $250.00 Plan Pays 80% $28.00 Plan Pays 80% $28.00 Patient Coins. 20% $7.00 COB/Primary Applied $28.00 Patient Responsibility $272.00* Patient Pays $244.00* *Member should not pay provider until they receive secondary Explanation of

• Benefits. Final patient responsibility/paid is $244.00.

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Claim Example 4

Internal Dual Coverage

Plan A. Office visit with procedure. Plan A. Office visit with procedure. Network provider. Deductible met. Network provider. Deductible met. Primary Account: Secondary Account: Allowable $300.00 Allowable $300.00 Patient Co-Pay $15.00 Patient Co-Pay $15.00 Plan Pays 80% $228.00 COB/Primary Applied $228.00 Patient Coins. 20% $57.00 Plan Pays 80% $72.00 Patient Responsibility $72.00* Patient Pays $0.00*

Total owed to provider is $300.00, all paid by Plan. Because the balance after primary account was only $72.00, the secondary account will pay up to that amount. *Member should not pay provider until they receive secondary Explanation of

• Benefits. Final patient responsibility/paid is $0.00.

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Claim Example 5

Internal Dual Coverage Plan B. Network Provider. Deductible Plan B. Network provider. Deductible not met. not met. Primary Account: Secondary Account: Allowable $2000.00 Allowable $2000.00 Patient Co-Pay $25.00 Patient Co-Pay $25.00 Balance to Deductible $1000.00 Balance to Deductible $1000.00 Plan Pays 70% $682.50 Plan Pays 70% $682.50 Patient Responsibility $1317.50* COB/Primary Applied $682.50 Patient Pays $635.00* Total owed to provider is $2000.00. $1365 paid by Plan & $635.00 by patient. *Member should not pay provider until they receive secondary Explanation of

• Benefits. Final patient responsibility/paid is $635.00.

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Claim Example 6

Internal Dual Coverage Plan B. Network Provider. Deductible Plan B. Network provider. Deductible met. met. Primary Account: Secondary Account: Allowable $50.00 Allowable $50.00 Patient Co-Pay $25.00 Patient Co-Pay $25.00 Plan Pays 70% $17.50 Plan Pays 70% $17.50 Patient Responsibility $32.50* COB/Primary Applied $17.50 Patient Pays $15.00* Total owed to provider is $50.00. $35 paid by Plan & $15.00 by patient. *Member should not pay provider until they receive secondary Explanation of

• Benefits. Final patient responsibility/paid is $15.00.

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Claim Example 7

Internal Dual Coverage Plan A. Network Provider. Deductible Plan B. Network provider. Deductible not met. not met. Primary Account: Secondary Account: Allowable $50.00 Allowable $50.00 Patient Co-Pay $15.00 Patient Co-Pay $25.00 Balance to Deductible $35.00 Balance to Deductible $25.00 Plan Pays $0.00 Plan Pays $0.00 Patient Responsibility $50.00* Patient Pays $50.00* Total owed to provider is $50.00, all paid by patient *Member should not pay provider until they receive secondary Explanation of

• Benefits. Final patient responsibility/paid is $50.00.

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Claim Example 8

Internal Dual Coverage Plan A. Network Provider. Deductible Plan B. Network provider. Deductible met. met. Primary Account: Secondary Account: Allowable $50.00 Allowable $50.00 Patient Co-Pay $15.00 Patient Co-Pay $25.00 Plan Pays $35.00 COB/Primary Applied $35.00 Patient Responsibility $15.00* Plan Pays $15.00 Patient Pays $0.00 Total owed to provider is $50.00, all paid by Plan *Member should not pay provider until they receive secondary Explanation of

• Benefits. Final patient responsibility/paid is $0.00.

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Claim Example 9

External Dual Coverage

FUSD Secondary - Plan A. Network provider. Primary Plan (not FUSD): Secondary Plan (FUSD): Allowable $100.00 Allowable $90.00 Patient Co-Pay $20.00 Patient Co-Pay $15.00 Plan Pays $80.00 COB/Primary Applied $80.00 Patient Responsibility $20.00 Plan Pays $10.00 Patient Responsibility $0.00 Provider owed $90.00 for FUSD. Primary paid $80.00, so FUSD will pay remaining $10.00. Final patient responsibility/paid is $0.00.

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