1. What is
The Double Coverage clause
is a standard provision in the FEHB program contracts. It exists
when individuals covered under our Plan are also eligible for
2. What is COB?
COB stands for "coordination of benefits."
It is a standard insurance industry system for the payment of
claims when an individual is covered by two or more group health
or accident policies (double coverage). When Double Coverage exists,
one plan will be considered primary (Pays its benefits first)
and the other plan will be secondary (see number 3). After the
primary plan has paid its benefits, the secondary plan will coordinate
(supplement) benefits with the primary's payment allowing a combined
payment of up to, but not more than, 100% of covered charges.
It is possible in certain situations that both plans would pay
their regular contract allowances which, when added together,
would not total 100% of covered expenses. This usually occurs
when covered expenses only exceed the deductible by a small amount.
3. Who Pays
Recognizing the complexities of Double
Coverage, the health insurance industry with the cooperation of
the National Association of Insurance Commissioners (NAIC) developed
a system for determining the primary payer which is called the
"Order of Benefit Determination." Our contract requires
the Plan to follow these guidelines.
For dependent children the "birthday
rule" governs. If a child is covered under both parents'
insurance companies (divorced or separated parents excluded),
the primary carrier is determined by the plan covering the
parent whose birthday, excluding year of birth, occurs earlier
in a calendar year. If the other insurance company does not
have this provision, the father's plan may be primary;
When the parents are separated or divorced,
the primary carrier is the plan covering the child as a dependent
of the parent with custody (unless this is contrary to a court
determination). If the parent with custody has remarried,
the plan covering the step-parent pays benefits second, and
the plan covering the parent without custody pays benefits
third. If a court awards joint custody the "birthday
The plan covering the person as an
active employee pays benefits first.The plan covering the
person as a laid off or retired employee pays benefits second;
The plan covering the person through
temporary continuation of coverage (TCC) is ALWAYS secondary;
If none of the above apply, the plan
that has insured the patient longer is primary;
- If no other rules apply, then the medical
expenses are shared equally between all plans.
4. How to File With
When you have Double Coverage, obtain duplicate
copies of all medical bills.
- If the other plan is primary, send
the original bills to the other insurance carrier.
- When you receive the other carriers
explanation of benefits and/or letter of denial, send it with
the other set of bills to the NALC Health Benefit Plan. The
reverse would be followed if NALC is primary.
Failure to follow the above filing procedures may result in delay
In order to maintain current
records, the Plan must be notified of changes in your enrollment
with your other coverage.
5. What is NOT Double
If an individual is eligible for benefits
through a nongroup individual policy and the premiums are paid
by the policyholder direct to the insurance company, Double Coverage
does not exist and the NALC Health Benefit Plan will pay its contract
allowance without regard to any payments made by the other insurance
Benefits received under the following are
not considered Double Coverage under the NALC Health Benefit Plan:
Income protection plans such as those
that pay a fixed sum per day, week or month while disabled;
Student, school or newspaper
Medical payment provisions of home
owners and automobile policies;
Tricare; and Uniformed Services Family
Health Plan (USFHP)
Federal State "Medicaid"
- Hospital indemnity policies that pay
$200 per day or less.
6. Additional Information