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 reasons?
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 (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 (Medicare entitlement date was 12/01/2023, 3-Month waiting period waived)
What are the key factors to determining COB?
Active employment and Medicare entitlement reason/date.
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 will they have a 30-Month COB?
No. 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 (Medicare entitlement date is 07/01/2022 after 3-Month waiting period)
Name a type of plan that does not coordinate with Medicare.
QHP/Exchange (It is illegal to sell a QHP plan to a person with Active Medicare. Medicare will be primary over exchange regardless of entitlement reason)
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 reason?
12 months after the last month of dialysis treatments, or regain kidney function.
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 does COB end?
12/31/2023 (person is entitle to additional COB periods when transplant is greater than 36 months, no waiting period)
What is the name of the document that is required under ERISA that ensures transparency for participants about their rights, benefits and obligations under the plan?
What is the Summary Plan Description (SPD).
(This document is frequently reviewed when understanding how Employers determine COB)
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 or another qualifying disability
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.
Patient FDODE is 01/15/2024. Patient started HHD training 05/01/2024, when does COB end?
09/30/2026 (HHD training would waive 3-month waiting period but not in this case because training began after initial 90 days)