West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-28 - Coordination Of Health Benefits › Appendix B - CONSUMER EXPLANATORY BOOKLET

Current through Register Vol. XLI, No. 28, July 12, 2024
COORDINATION OF BENEFITS
IMPORTANT NOTICE
This is a summary of only a few of the provisions of your
				  health plan to help you understand coordination of benefits, which can be very
				  complicated. This is not a complete description of all of the coordination rules and
				  procedures, and does not change or replace the language contained in your insurance
				  contract, which determines your benefits
.
Double Coverage
It is common for family members to be covered by more than one
				  health care plan. This happens, for example, when a husband and wife both work and
				  choose to have family coverage through both employers.
When you are covered by more than one health plan, state law
				  permits your insurers to follow a procedure called "coordination of benefits" to
				  determine how much each should pay when you have a claim. The goal is to make sure
				  that the combined payments of all plans do not add up to more than your covered
				  health care expenses.
Coordination of benefits (COB) is complicated, and covers a wide
				  variety of circumstances. This is only an outline of some of the most common ones.
				  If your situation is not described, read your evidence of coverage or contact your
				  state insurance department.
Primary or Secondary?
You will be asked to identify all the plans that cover members of
				  your family. We need this information to determine whether we are the "primary" or
				  "secondary" benefit payer. The primary plan always pays first when you have a
				  claim.
Any plan that does not contain your state's COB rules will always
				  be primary.
When This Plan is Primary
If you or a family member are covered under another plan in
				  addition to this one, we will be primary when:
Your Own Expenses
$ The claim is for your own health care expenses, unless you are
				  covered by Medicare and both you and your spouse are retired.
Your Spouse's Expenses
$ The claim is for your spouse, who is covered by Medicare, and
				  you are not both retired.
Your Child's Expenses
$ The claim is for the health care expenses of your child who is
				  covered by this plan and
$ You are married and your birthday is earlier in the year than
				  your spouse's or you are living with another individual, regardless of whether or
				  not you have ever been married to that individual, and your birthday is earlier than
				  that other individual's birthday. This is known as the "birthday rule"; or
$ You are separated or divorced and you have informed us of a
				  court decree that makes you responsible for the child's health care expenses;
				  or
$ There is no court decree, but you have custody of the
				  child.
Other Situations
We will be primary when any other provisions of state or federal
				  law require us to be.
How We Pay Claims When We Are Primary
When we are the primary plan, we will pay the benefits in
				  accordance with the terms of your contract, just as if you had no other health care
				  coverage under any other plan.
How We Pay Claims When We Are Secondary
We will be secondary whenever the rules do not require us to be
				  primary.
How We Pay Claims When We Are Secondary
When we are the secondary plan, we do not pay until after the
				  primary plan has paid its benefits. We will then pay part or all of the allowable
				  expenses left unpaid, as explained below. An "allowable expense" is a health care
				  expense covered by one of the plans, including copayments, coinsurance and
				  deductibles.
$ If there is a difference between the amount the plans allow, we
				  will base our payment on the higher amount. However, if the primary plan has a
				  contract with the provider, our combined payments will not be more than the amount
				  called for in our contract or the amount called for in the contract of the primary
				  plan, whichever is higher. Health maintenance organizations (HMOs) and preferred
				  provider organizations (PPOs) usually have contracts with their providers.
$ We will determine our payment by subtracting the amount the
				  primary plan paid from the amount we would have paid if we had been primary. We may
				  reduce our payment by any amount so that, when combined with the amount paid by the
				  primary plan, the total benefits paid do not exceed the total allowable expense for
				  your claim. We will credit any amount we would have paid in the absence of your
				  other health care coverage toward our own plan deductible.
$ If the primary plan covers similar kinds of health care
				  expenses, but allows expenses that we do not cover, we may pay for those
				  expenses.
$ We will not pay an amount the primary plan did not cover because
				  you did not follow its rules and procedures. For example, if your plan has reduced
				  its benefit because you did not obtain pre-certification, as required by that plan,
				  we will not pay the amount of the reduction, because it is not an allowable
				  expense.
Questions About Coordination of Benefits?
Contact Your State Insurance
				  Department