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. 

(3) The standards provided in subsection (2) apply to coordination of benefits payable under Medicare, Title XVIII of the Social Security Act. 

(4) If a claim is submitted in accordance with any group hospital, medical, or surgical expense policy, or in accordance with any group health care service plan or group-type self-insurance plan, that provides protection, insurance, or indemnity against hospital, medical, or surgical expenses, and the policy or any other document that provides coverage includes a coordination-of-benefits provision and the claim involves another policy or plan which has a coordinationof-benefits provision, the following rules determine the order in which benefits under the respective health policies or plans will be determined: 

(a)1. The benefits of a policy or plan which covers the person as an employee, member, or subscriber, other than as a dependent, are determined before those of the policy or plan which covers the person as a dependent.