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7 Rules of COB part 1

100

• The plan that covers the person as an employee, enrollee, subscriber, or retiree (other than as a dependent) will be primary to a plan that covers same person as a dependent.
• This rule applies when:
  • Both spouses cover each other as dependents under their respective plans
  • A dependent student has coverage that meets the definition of group health plan coverage.
    References:

Rule #1- 

Non-dependent/Dependent

200

• If preceding rules do not determine the order of benefits, the benefits of the plan that covered an employee longer are determined to be primary over those that covered the employee for a shorter period of time.
• There are instances when an employee has two jobs and is covered under group plans with each employer.

Rule 6-

Longer/Shorter Length of Coverage

300

In the case of divorce or separation, court decree may give one parent financial responsibility for the medical, dental, or other healthcare expenses of the dependent child. 

Rule 3- Dependent Child Separated or Divorced 

400

This includes parents who live together, but are not married.

• The plan of parent/legal guardian whose birth date is earlier in the calendar year will be primary for children, and plan of parent/legal guardian whose birth date is later in the calendar year will be secondary.
• The term birthday refers only to the month and day in a calendar year, not year person was born.

Rule 2- Birthday Rule

500

COBRA with Other Group Health Plan Coverage

• There are situations when individuals can be covered under a group health plan and under a COBRA plan. If an individual was covered with a group health plan with their employer and had coverage under another group health plan through their spouse, they would have two group health coverages. If that individual then moved to a COBRA plan through their employer, they can still retain the group health coverage through their spouse. They would then have a COBRA plan and group health coverage.

Rule 5-

COBRA Continuation of Coverage

COB part 2

100

• A plan that covers a person as an employee - who is neither laid off nor retired - is primary. The other plan may not have a rule for laid off or retired employees similar to this rule. In this case, Rule 4 is ignored.
• The only situation in which the laid off/retiree rule may apply is when a member is employee/subscriber for both the active and inactive plan. Therefore, if member is a subscriber on an inactive plan and is a spouse or dependent on an active plan, then the plan in which member is a retiree is primary.

Rule 4- active/inactive employee (laid off/reiree)

200

If none of the rules from above apply, both plans should share expenses equally. One insurance company would call the other and inquire what its allowable would be. The plan with the higher allowable would then be used by each company, and each company would pay 50% of the higher allowable expense. This would allow the higher benefit to the enrollee.

Rule 7- Shared Expenses 

300

The advocacy you can find the 7 Rules of COB

Eligibility advocacy 

400

The 2 systems we use to update COB

ISET and CDB

500

The TAB and sub tab in iset where you can update COB

Eligibility- other insurance