High Option Plan

Double Coverage and COB

What is Double Coverage?

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 benefits under—

• Any other kind of group health or accident plan regardless of who pays the premiums, for example:
• When your spouse works or you have a second job and either or both have insurance through that employment;
• When you have insurance through an association or other organization; or
• When unmarried dependent children under age 27 work and have insurance through their employment;
• Automobile insurance that pays without regard to fault;
• Part A and/or Part B or Medicare Advantage (formerly called Medicare+Choice)

Additional information on this is available upon request and in the Plan's brochure.

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. 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.

Who Pays First?

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.

• The Plan that covers the patient as the employee (member) pays before the plan that covers the patient as a dependent;
• 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 rule" applies;
• 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.

How to File With NALC.

When you have Double Coverage, obtain duplicate copies of all medical bills.

1. If the other plan is primary, send the original bills to the other insurance carrier.
2. When you receive the other carrier’s 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 of payment.

In order to maintain current records, the Plan must be notified of changes in your enrollment with your other coverage.

What is NOT Double Coverage?

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 company.

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;
• Individual policies;
• Student, school or newspaper delivery insurance;
• Medical payment provisions of home owners and automobile policies;
• Tricare; and Uniformed Services Family Health Plan (USFHP)
• Federal — State "Medicaid" Programs;
• Hospital indemnity policies that pay $200 per day or less.

Additional Information

For details describing all of the benefits, refer to the NALC Health Benefit Plan Brochure (RI 71-009).

For other information and verification, contact the Plan at:

20547 Waverly Court
Ashburn, Virginia 20149-0001
888-636-6252