Coordination of Benefits (C.O.B.) occurs when a person has more than one insurance policy (for example, when you are covered on your own plan as well as a spouse’s plan, or you and your spouse both cover your dependents.) All plans offered by 4J coordinate benefits, but some other employer plans may not.  It’s important to check with the other insurance company to determine whether they will coordinate benefits before choosing to be double-covered.  In some cases it may be more advantageous to only have one plan.

The rules governing C.O.B. are dictated by state and federal law and monitored by the Department of Insurance.  As long as a plan has designated that they will coordinate benefits, neither the employee nor the employer have control over the details of the coordination.  The details of how C.O.B. works is uniform across the state.  Although these details can seem quite complicated on the surface, it’s important to realize that if you are double-covered with two plans that both coordinate benefits, you will always get the maximum amount of benefit available, regardless of which plan is primary or secondary.  (For more details on why this is true, please see the FAQ’s below.)

In reviewing the information about how C.O.B. works, consider these general guidelines:

• The plan that covers the individual as an employee is primary. The plan that covers the individual as a dependent is secondary.
• The spouse whose birthday is earliest in the year, or who has custody of a child, holds the primary coverage for dependent children.
• The primary plan always pays the same benefits as it would if there were no secondary plan.

The Primary Plan (which is the plan that pays benefits first) pays the benefits that it would have paid were there no other insurance available.

The Secondary Plan (which is the plan that pays benefits after the Primary Plan) will limit the benefits it pays so that the sum of its benefit and all other benefits paid by the Primary Plan will not exceed the greater of:

• 100% of the total maximum plan allowance.
• The amount of the benefits it would have paid had it been the Primary Plan.

With the exception of pharmacy claims, your provider should be able to submit the claim to both plans on your behalf and the two insurance companies work out the details.  Your provider should provide you with a detailed statement showing the total cost for their services, how much each of the plans paid and any remaining “patient responsibility” balance, if applicable.  Be sure providers are aware of the proper information for both plans so they can provide this service for you.

For pharmacy claims subject to the COB provision of the Plan may be submitted electronically by pharmacies or through the direct member reimbursement paper claim process. The preferred method is for the pharmacy to electronically transmit the primary plan’s remaining balance to Moda Health for processing. If approved, the secondary claim will be automatically processed according to plan benefits. Members who are unable to have their secondary claims processed electronically may submit a claim reimbursement request directly to Moda Health.

If your 4J OEBB plan is the secondary coverage, you can use this form to submit the receipt.   If your secondary coverage is not through 4J, please check with that plan for instructions on how to submit prescription claims.

For medical, vision and dental services, send the explanation of benefits (EOB) received from the primary carrier and a copy of itemized billings to the secondary carrier with a request for pickup of co-pays or other eligible costs. For pharmacy bills, send your original receipt along with the required reimbursement form to the secondary carrier for pickup of eligible expenses. If your pharmacy plan provides an EOB, it must also be sent with the receipt. Keep copies of all receipts and statements sent.