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Coordination of Benefits (COB)
NYC Health Benefits Program
You may be covered by two or more group health benefit plans that may provide similar benefits. If you have coverage through more than one plan, your City health plan will coordinate benefit payments with the other plan. One plan will pay its full benefit as a primary insurer, and the other plan will pay secondary benefits. This prevents duplicate payments and overpayments. The plan covering you as an employee is primary before a plan covering you as dependent. In no event shall payments exceed 100% of a charge.
Special Rules for Dependents of Separated or Divorced Parents
If two or more plans cover a dependent child of divorced or separated parents, benefits are to be determined in the following order:
- The plan of the parent who has custody of the child is primary.
- If the parent with custody of a dependent child remarries, that parent’s plan is primary. The step-parent’s plan is secondary and the plan covering the parent without custody is third.
- If the specific decree of the court states one parent is responsible for the health care of the child, the benefits of that parent’s plan are determined first. You must provide the appropriate plan with a copy of the portion of the court order showing responsibility for health care expenses of the child.
11 CRR-NY 52.23 NY-CRR
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The Coordination of Benefits Agreement (COBA) program establishes a uniform national contract between CMS, benefit programs and other health insurers. COBA is a standard processing methodology used by the national Medicare community. COBA allows greater efficiency and simplification via consolidation of the claims crossover process.
Under COBA, Medicaid providers will submit claims for Medicare/Medicaid eligible beneficiaries to the Medicare fee-for-service claims system for processing. Medicare will:
- Process the claim
- Apply any deductible/coinsurance or co-pay amount
- Forward the claim to Fidelis Care for further claims processing.
For claim types included in the COBA agreement, providers will no longer need to bill Medicaid separately for the Medicare deductible, coinsurance or co-pay amounts. Please note, it is crucial that providers provide the appropriate NPI number and TIN on the claim form in order to ensure seamless processing by Fidelis Care.
If you have any questions, please contact your Fidelis Care Provider Relations Specialist, or connect with our Call Center at 1-888-FIDELIS (1-888-343-3547).
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Health insurance will no longer be automatically renewed for Medicaid Managed Care, Essential Plan, Child Health Plus, or HealthierLife members.
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