COB Basics
What is COB?
When an individual is covered by more than one health plan COB is the determination of which health insurance plan has the primary payment responsibility and the extent to which the other plans will contribute.
What are each of the Medicare entitlement qualifications?
Age (65), disability, and/or ESRD.
What is the Subscriber Rule?
The policy holder's policy is primary over another policy where they are a covered dependent.
When does Medicare coverage begin if entitled due to ESRD?
If training is received within 90 days of FDODE Medicare will begin on the 1st of the Month ESRD begins.
If no training is received within 90 days of FDODE Medicare will begin on the 1st of the Month following the 3-Month waiting period.
Patient FDODE was 11/12/2020. ICHD and no training received, when does COB end?
07/31/2023 and Medicare primary on 08/01/2023. (Medicare entitlement date is 02/01/2021 after 3-Month waiting period)
What is MSP?
Medicare Secondary Payer- When the Medicare program does not have primary payment responsibility. When another entity has the primary responsibility for paying before Medicare.
A person is entitlement due to age, their birthday is on the 1st of the month. When does Medicare entitlement start?
Medicare entitlement will start the month BEFORE their 65th birthday.
(B-Day June 1st, Medicare entitlement May 1st)
What is the Effective Date Rule?
If covered by two EGHP's, the policy with the earliest effective date is primary.
Common name for the 'End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration' form.
What is the CMS 2728?
Patient FDODE was 12/07/2023. Patient completed PD training w/in initial 90 days, when does COB end?
05/31/2026 and Medicare is primary 06/01/2026 (Medicare entitlement date was 12/01/2023, 3- Month waiting period waived)
Active employment and Medicare entitlement reason/date.
What is the key to determining COB?
What is the difference between Medicare eligibility and Medicare entitlement?
Medicare Eligible- person qualified for Medicare, meets one of the conditions for coverage and would receive it IF they applied
Medicare Entitled- person is qualified for Medicare, meets one of the conditions for coverage, has applied and MCARE ID has been issued
What is the Birthday Rule?
If a dependent is covered by more than one EGHP with different subscribers, the primary policy will be based off of whoever's birthday occurs first. (Not by year but by month)
If a patient never gets ESRD, what is the COB period?
None- If a person never gets ESRD the EGHP will be primary payer as long as person is actively working.
Patient FDODE was 04/28/2022. Patient never received training, when does COB end?
12/31/2024 and Medicare primary on 01/01/2025. (Medicare entitlement date is 07/01/2022 after 3-Month waiting period)
Name 2 types of plans that do not coordinate with Medicare.
QHP/Exchange
Veterans Administration
Workers Comp (if injury resulted in ESRD)
Jails/Prisons (Medicare benefits suspend while incarcerated)
Payer of Last Resort (Medicaid, I.H.S, State Renal Plans, Medigap plans)
What 2 qualifications must be meet for a Medicare entitled person to be approved for Medicare?
Citizenship (must be a U.S Citizen or Legal Resident)
Work Quarters (40 quarters for age 65, quarters is reduced if under 65)
What is the Gender Rule?
If a dependent is covered by more than one EGHP with different subscribers and the birthday rule is not followed, when possible the male subscriber's policy is primary over the female subscriber's policy.
When can Medicare coverage end if ESRD is the only entitlement?
12 months after the last month of dialysis treatments.
36 months after the month of the kidney transplant.
Patient FDODE was 07/15/2021. Patient is returning to dialysis after failed successful transplant, when did COB end?
12/31/2023 and Medicare is primary 01/01/2024 (person is entitled to ONE additional COB period when transplant is greater than 36 months, no waiting period).
A time frame when an EGHP coverage is primary for individuals with ESRD who are also eligible for Medicare.
What is the 30-Month coordination period?
For a child to be eligible for Medicare, what qualifications must apply to the Parent and what conditions must apply to the child?
Child- Must be diagnosed with ESRD or has had a Kidney transplant
Parent- Must meet reduced work credits or getting/eligible for Social Security
What is the Retiree's Rule?
A person covered by 2 EGHP's, one through active employment and on as a retiree- the policy through active employment is primary, regardless of who owns the policy.
If a patient has a successful failed transplant, what will the COB period be?
30 months- If a transplant fails after 36 months there will be no 3-month waiting period. Person is only entitlement to ONE additional COB period.
(If an additional transplant fails after the 36 months and the beneficiary enrolls in Medicare, there will be no COB period and Medicare coverage will start right away)
Patient FDODE was 01/15/2024. Patient started HHD training 05/01/2024, when does COB end?
09/30/2026 and Medicare is primary 10/01/2026 (HHD training would waive 3 month waiting period, but patient began training after initial 90 days)