Coordination Of Benefits
Coordination of Benefits (COB) is a provision in group health and group dental contracts that prevent duplicate payments for the same covered medical or dental expenses. The COB provision applies only when a participant or eligible dependent is covered under more than one group health or dental program. When that is the case, the Welfare Fund will coordinate benefit payments with the other group plan. One group will pay its full benefit as the primary plan and the other group will pay secondary benefits (if necessary) to cover some or all of the remaining expenses. This COB provision prevents duplicate payments and overpayments. In no case should the benefits received from the two group plans in total be greater than the medical or dental allowed charges.
The rules to determine the order of payment under Welfare Fund coverage in those cases where there is coverage under more than one group plan are as follows:
- If the other group plan does not have a COB provision similar to the Welfare Fund's, then that group will be primary.
- If both groups have a COB provision, the group covering the person as a participant is primary.
- If a dependent child is covered under both parents' gourp plan and the parents are not separated or divorced, the plan of the parent whose birthday falls earlier in the year will be primary. For purposes of determining the earlier birthday only the month and day are considered; the year of birth has no significance. If both parents have the same birthday, the plan which covered the parent longer will be primary. However, if the other group plan does not use the "birthday rule;" but instead uses a rule based on the gender of the parent and as a result the two plans do not agree on which is primary, then the father's group plan shall be primary.
- If a dependent child is covered under both parents' group plan, the parents are separated or divorced, there is no court decree which establishes financial responsibility for the child's coverage, the plan of the parent who has custody (the custodial parent) shall be primary. However, if the custodial parent has remarried and the child is also covered as a dependent under the step-parent's plan, the custodial parent's plan will pay first, the step-parent's plan second and the non-custodial parent's plan third.
- If a court decree specifies which parent is to be responsible for the child's coverage and that parent's plan has actual knowledge of the decree, then that parent's plan will be primary.
- If a person is covered under one group as an active participant or as the dependent of an active participant and is also covered under another group as a retired participant or as the dependent of a retired participant, the group which covers that person as an active participant is primary. If the other group plan does not have this rule, and as a result the two plans do not agree on which is primary, then this rule will be ignored.
- If none of the above rules determine which group plan is primary, the group plan covering the person for the longer period of time is primary.