Medicare benefits

However, if the person is also a Medicare beneficiary, and if the rule established under the Social Security Act of 1965, as amended, makes Medicare secondary to the plan covering the person as a dependent of an active employee, the order of benefit determination is:

a. First, benefits of a plan covering a person as an employee, member, or subscriber.

b. Second, benefits of a plan of an active worker covering a person as a dependent. 

c. Third, Medicare benefits.  

(b) Except as stated in paragraph (c), if two or more policies or plans cover the same child as a dependent of different parents: 

1. The benefits of the policy or plan of the parent whose birthday, excluding year of birth, falls earlier in a year are determined before the benefits of the policy or plan of the parent whose birthday, excluding year of birth, falls later in that year; but 

2. If both parents have the same birthday, the benefits of the policy or plan which covered the parent for a longer period of time are determined before those of the policy or plan which covered the parent for a shorter period of time. 

However, if a policy or plan subject to the rule based on the birthdays of the parents coordinates with an out-of-state policy or plan which contains provisions under which the benefits of a policy or plan which covers a person as a dependent of a male are determined before those of a policy or plan which covers the person as a dependent of a female and if, as a result, the policies or plans do not agree on the order of benefits, the provisions of the other policy or plan determine the order of benefits. 

(c) If two or more policies or plans cover a dependent child of divorced or separated parents, benefits for the child are determined in this order: 

1. First, the policy or plan of the parent with custody of the child. 

2. Second, the policy or plan of the spouse of the parent with custody of the child. 

3. Third, the policy or plan of the parent not having custody of the child. 

However, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child and if the entity obliged to pay or provide the benefits of the policy or plan of that parent has actual knowledge of those terms, the benefits of that policy or plan are determined first, except with respect to any claim determination period or plan or policy year during which any benefits are actually paid or provided before the entity has the actual knowledge. 

(d) The benefits of a policy or plan which covers a person as an employee who is neither laid off nor retired, or as that employee's dependent, are determined before those of a policy or plan which covers the person as a laid-off or retired employee or as the employee's dependent. If the other policy or plan is not subject to this rule, and if, as a result, the policies or plans do not agree on the order of benefits, this paragraph does not apply. 

(e) If none of the rules in paragraph (a), paragraph (b), paragraph (c), or paragraph

(d) determine the order of benefits, the benefits of the policy or plan which covered an employee, member, or subscriber for a longer period of time are determined before those of the policy or plan which covered the person for the shorter period of time. 

(5) Coordination of benefits is not permitted against an indemnity-type policy, an excess insurance policy as defined in s. 627.635, a policy with coverage limited to specified illnesses or accidents, or a Medicare supplement policy. 

COB – Coordination of Benefits

Sometimes a patient will have more than one health insurance policy. This could be a patient with Medicare and Medicaid. Medicaid is usually the health care benefit that is billed last. The patient could have Medicare and coverage under the Veterans Administration. The patient could be covered under health care provided as a benefit of employment through their own employer or through their spouses employer. If so, the two insurance companies are required to determine which policy is primary or which is secondary. Cob also includes other factors such as birthdate of parents who is providing healthcare to a child. Some states have laws regulating coordination of benefits.

627.4235 Coordination of benefits.-- 

(1) A group hospital, medical, or surgical expense policy, group health care services plan, or group-type self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses delivered or issued for delivery in this state must contain a provision for coordinating its benefits with any similar benefits provided by any other group hospital, medical, or surgical expense policy, any group health care services plan, or any group-type self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses for the same loss.

(2) A hospital, medical, or surgical expense policy, health care services plan, or self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses issued in this state or issued for delivery in this state may contain a provision whereby the insurer may reduce or refuse to pay benefits otherwise payable thereunder solely on account of the existence of similar benefits provided under insurance policies issued by the same or another insurer, health care services plan, or self-insurance plan which provides protection or insurance against hospital, medical, or surgical expenses only if, as a condition of coordinating benefits with another insurer, the insurers together pay 100 percent of the total reasonable expenses actually incurred of the type of expense within the benefits described in the policies and presented to the insurer for payment.