what is a coordination of benefits

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Benefits of Having 2 Health Insurance Plans

How Does Having More Than One Health Plan Work?

What Is Coordination of Benefits?

How having two health plans works.

• Should You Keep Two Health Insurance Plans?

Understanding Coordination of Benefits System

Medicare combined with a group plan, reasonable and customary costs, you may still need to pay some costs, frequently asked questions (faqs).

The Balance / Bailey Mariner

Having access to two health plans can be good when making health care claims. Having two health plans can increase how much coverage you get. You can save money on your health care costs through what's known as the "coordination of benefits" provision. Here's what you need to know about using two health care plans and how it works.

Key Takeaways

• Having access to two health plans can increase how much coverage and save money on your health care costs through the "coordination of benefits" provision.
• When an insured person has two health plans, one is the main plan, and the other is the second plan.
• In there's a claim, the primary health plan pays out first, while the second plan pays some or all of the costs the first plan didn't pay.
• If you and your spouse or partner both have a health care plan at work, and your children are covered on both plans, the second plan can pay some of the costs the first plan didn't.

When a person is covered by two health plans , coordination of benefits is the process the insurance companies use to decide which plan will pay first and what the second plan will pay after the first plan has paid.

As an example, if your spouse or partner has a health care plan at work, and you have access to one through work as well, your children could have coverage through both plans. Once the main plan pays, rather than having to pay the rest, you could see the second plan paying some of what you would have had to pay if you didn't have it. You can use both plans to get the most out of your children's health care.

In some cases, one plan may provide better care in one area, like mental health coverage . The other plan may offer better coverage in some other area. You can get the best of two health plans when you combine care.

When an insured person has two health plans, one is the main plan, and the other is the second one. In the event of a claim, the primary health plan pays out first. The second one kicks in to pay some or all of the costs the first plan didn't pick up. Some of the health care costs to consider when deciding how to manage your health care plans are outlined below.

Your deductible is the amount you need to pay out of pocket each year before your insurance covers any of your medical costs, including appointments and prescriptions. For example, your insurance plan might have a $2,000 annual deductible, which means you need to cover the first $2,000 in costs each year before your insurance covers any expenses.

A copay —short for copayment—is an amount you pay at the time of each doctor’s appointment. Typically it's a small fee, such as $15 or $25 for your primary doctor. However, the copay might be higher for a specialist or other service.

Coinsurance

Coinsurance is a set percentage of the cost of service that you must share in paying. For example, your insurance provider might pay 80% of the cost of a service, while you'd be responsible for 20%. Coinsurance costs can be expensive if you or a family member need extensive care, such as a hospital stay or surgery.

Should You Keep Two Health Care Plans? 

If you have access to two health care plans, you could end up paying less money out of your own pocket for expenses the first plan doesn't cover. For example, if your first plan has a deductible or copay, the second plan may pay for that.

Does a person with two health care plans get double benefits? Not exactly. Having two health plans does help cover any health care costs better through the coordination of benefits provision.

If you are thinking you will save money on health insurance by only having one plan, think about how combining care works and what health care costs you have before signing a health insurance waiver and giving up a second plan. If your plan through your own job is free, and your partner can add you to their plan for a low cost, you should keep both plans.

Here's how a person may have two health care plans:

• A child's parents each have access to a health plan at work. Children can be covered under both plans if the parents decide to include them.
• Married couples or domestic partners who each have access to a health plan through their job may put each other on their plans.

The health plan coordination of benefits system is used to ensure both health plans pay their fair share. When both health plans combine coverage in the right way, you can avoid a duplication of benefits while still getting the health care to which you're entitled.

Health plans combine benefits by looking at which health plan is the patient's main plan and which one is the backup plan. There are guidelines set forth by the state and health plan providers that help the patient's health plans decide which health care plan is the main plan and which is the second plan.

If you have two health plans, you may be asked to declare which one you want to name as your main plan. Do your research to decide which plan will work better as your main plan.

Once you've named one plan as your first plan, that plan will pay what is required without looking at what the second plan covers. Once the main plan has paid the costs it has to pay, the second plan will be used.

Your second health plan, unlike your first plan, can look at what health care service was provided to you by the main plan. The health care costs that are still due will then be looked at for payment under the second health care plan.

If you’re 65 or older, have group health plan coverage based on your or your spouse's current employer, and it has 20 or more employees, the group plan will pay first. If they have less than 20 employees, Medicare will kick in first.

There are some rules that health plan providers follow that could cause a person covered by two plans to still have to pay for some health care costs . One such area is the "reasonable and customary" amount.

Most health plans will only cover costs that are reasonable and customary. In other words, the health plan provider will not pay for any services or supplies that are being billed at a cost that is more than what is the usual charge for the treatment in the area where the treatment takes place.

Once your main plan pays the reasonable and customary amount on a health care service, there may still be a balance due. This could happen if the health care provider was charging more than what the main plan felt was reasonable and customary.

The second plan does not have to pay the amount the first plan did not pay if the charge is deemed out of the normal limit. The insured person could still end up paying out-of-pocket. This could still happen even if there are two health plans.

What's more, neither health care plan will cover the cost of a service that is not covered under their health care plans. If both plans do not cover a certain test, for example, the second one doesn't have to pay after the first one denies the expense.

People with more than one health care plan should discuss with their health plan providers how combining plans will work with their plans. This way, they can see what health care coverage they can expect.

If you have two insurances, will you have a copay?

If you have two health insurance plans, the second may pick up any copayments or additional costs that were not covered by your primary insurance. Your copay may or may not be covered. So, be sure to check with each of your insurance plans.

Will I lose my Medicaid when I am eligible for Medicare?

No, Medicaid and Medicare work together well, and between the two, most of your costs should be completely covered. Some states even offer Medicaid-Medicare plans that offer more coverage options.

National Association of Insurance Commissioners. " Using Your Health Plan ," Page 17.

Nebraska.gov. " Title 210 - Nebraska Department of Insurance: Chapter 39 - Coordination of Benefits Regulation ," Pages 24-26.

Nebraska.gov. " Title 210 - Nebraska Department of Insurance: Chapter 39 - Coordination of Benefits Regulation ," Pages 14, 18.

Nebraska.gov. " Title 210 - Nebraska Department of Insurance: Chapter 39 - Coordination of Benefits Regulation ," Page 1.

Nebraska.gov. " Title 210 - Nebraska Department of Insurance: Chapter 39 - Coordination of Benefits Regulation ," Page 17.

Centers for Medicare & Medicaid Services. " Medicare & Other Health Benefits: Your Guide to Who Pays First ," Pages 6, 12-13.

New York State. " Usual and Customary or Reasonable Fees for Health Insurance Reimbursements ."

National Association of Insurance Commissioners. " Coordination of Benefits Model Regulation ," Pages 120–1-120–2.

Medicare. " Medicaid ."

Coordination of Benefits: Everything You Need to Know

COB, or coordination of benefits, occurs when an individual is in possession of more than one insurance policy and it comes to processing a claim. 4 min read updated on February 01, 2023

Also referred to as COB, coordination of benefits occurs when an individual is in possession of more than one insurance policy and when it comes to processing a claim, the policies are assessed to determine which will be assigned with the primary responsibility for covering the predominant share of the claim costs.The process also involves assessing the extent that other policies held will contribute toward the claim. This article will provide you with everything that you need to know about coordination of benefits.

What Is Coordination of Benefits?

The primary intentions of coordination of benefits are to make sure that individuals who receive coverage from two or more plans will receive their complete benefit entitlement and to prevent benefits from being duplicated when an individual has more than one policy in place. This process covers insurance pertaining to several sectors including health insurance, car insurance, retirement benefits, workers compensation, and others.

The order in which the insurance policies are coordinated is dictated by insurance law and cannot be decided by a company or an individual. This process takes place only when multiple insurance plans are involved. If only one plan is held, then all responsibility is put onto the sole plan.

Predominantly, coordination of benefits happens when an individual has two plans in place (primary and secondary), but it may also include a tertiary plan in some circumstances. The primary insurance plan is given the responsibility of being the first payer, the secondary plan is the second payer, and so on depending on how many plans the individual holds.

Why Is COB Important?

There are numerous reasons why COB is an important process. These are summarized below:

• A lack of coordination between the plans a person holds can result in the claim not being paid until the COB has been confirmed, thus potentially causing financial difficulties.
• Either the individual or the insurance provider could be subjected to expenses that they did not need to pay if the insurance plans are not coordinated correctly.

Order of Benefit Determination

The primary plan is always considered as the predominant provider of benefits, and it must provide these as though the claim holder does not have a second or third policy in place. The COB provisions that are specified in the insurance policy outline which plan is the primary plan. Once identified, the primary plan's benefits are applied to the claim first.

It is important to note that the primary plan is always considered as the first payer, regardless of the specifics written in its clauses. This means that any plan that does not include the COB provisional clause may not incorporate the benefits offered by a claimant's other plan into their considerations when assessing what benefits are due.

Any unpaid balance owed to the patient is typically paid by the claimant's second plan, within the limits of its responsibility. This secondary insurance plan can take the benefits of the patient's other plans into consideration only when it has been confirmed as being the secondary — not primary — plan.

The payments that are delivered to the patient by their combined insurance plans do not exceed 100 percent of the charges for necessary covered services. The benefits are usually coordinated between all of the plans held by the patient.

If a family is making a claim, each individual and their COB will be assessed separately, as there is a possibility that the order of plans and benefits may differ between each member.

There may be some differences to the "order of benefit determination" as laid out here if the claimant's policy is held with Medicare, but otherwise, these rules should be followed as a standard process.

Understanding Various COB Rules

Common COB circumstances and how the COB rules are then applied are outlined below.

• Plan Type Rule If the individual has both a commercial insurance plan and Medicaid, then the commercial plan will always be considered as the primary policy, and Medicaid is secondary.
• Subscriber or Dependent Rule If a patient subscribes to two or more policies, where one policy is as a subscriber, and another is as a dependent, then the policy under which they are classified as a subscriber is the primary policy, and that where they are a dependent will fall as the secondary policy.
• Timeline Rule If the patient is the primary subscriber to two commercial plans, then the plan to which they have been subscribed the longest is considered as the primary plan, and the newer plan is the secondary.
• Employer Coverage Rule If the individual has coverage both through their employer and as a dependent through another commercial plan, then the employer-operated plan will always be considered as the primary plan.
• 1. The birthday rule of the parent (whoever's occurs earlier in the year) and,
• 2. The length of policy rule of the policy holders (whichever commenced first).
• Dependent Child (Parents Not Separated or Divorced) Rule If a child's parents are together, then determining the primary plan is done by using the birthday rule (i.e. whoever was born earlier is responsible).

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Coordination of Benefits and Recovery Overview

Guidance for Coordination of Benefits (COB) process that allows for plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities.

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: June 30, 2020

Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan).  

The COB Process:

• Ensures claims are paid correctly by identifying the health benefits available to a Medicare beneficiary, coordinating the payment process, and ensuring that the primary payer, whether Medicare or other insurance, pays first.
• Shares Medicare eligibility data with other payers and transmits Medicare-paid claims to supplemental insurers for secondary payment. Note: An agreement must be in place between the Benefits Coordination & Recovery Center (BCRC) and private insurance companies for the BCRC to automatically cross over claims. In the absence of an agreement, the person with Medicare is required to coordinate secondary or supplemental payment of benefits with any other insurers he or she may have in addition to Medicare.
• Ensures that the amount paid by plans in dual coverage situations does not exceed 100% of the total claim, to avoid duplicate payments.
• Accommodates all of the coordination needs of the Part D benefit. The COB process provides the True Out of Pocket (TrOOP) Facilitation Contractor and Part D Plans with the secondary, non-Medicare prescription drug coverage that it must have to facilitate payer determinations and the accurate calculation of the TrOOP expenses of beneficiaries; and allowing employers to easily participate in the Retire Drug Subsidy (RDS) program. Please click the Coordinating Prescription Drug Benefits link for additional information.

COB Data Sources

COB relies on many databases maintained by multiple stakeholders including federal and state programs, plans that offer health insurance and/or prescription coverage, pharmacy networks, and a variety of assistance programs available for special situations or conditions. Some of the methods used to obtain COB information are listed below:

Voluntary Data Sharing Agreements (VDSAs) - CMS has entered into VDSAs with numerous large employers. These agreements allow employers and CMS to send and receive group health plan enrollment information electronically. Where discrepancies occur in the VDSAs, employers can provide enrollment/disenrollment documentation. The VDSA data exchange process has been revised to include Part D information, enabling VDSA partners to submit records with prescription drug coverage be it primary or secondary to Part D. Employers with VDSAs can use the VDSA to submit their retiree prescription drug coverage population which supports the CMS mission of a single point of contact for entities coordinating with Medicare. Please click the Voluntary Data Sharing Agreements link for additional information.

COB Agreement (COBA) Program - CMS consolidates the Medicare paid claim crossover process through the COBA program. The COBA program established a national standard contract between the BCRC and other health insurance organizations for transmitting enrollee eligibility data and Medicare paid claims data. This means that Medigap plans, Part D plans, employer supplemental plans, self-insured plans, the Department of Defense, title XIX state Medicaid agencies, and others rely on a national repository of information with unique identifiers to receive Medicare paid claims data for the purpose of calculating their secondary payment. The COBA data exchange processes have been revised to include prescription drug coverage.

Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) – This law added mandatory reporting requirements for Group Health Plan (GHP) arrangements and for liability insurance, including self-insurance, no-fault insurance, and workers' compensation. Insurers are legally required to provide information.

Other Data Exchanges - CMS has developed data exchanges for entities that have not coordinated benefits with Medicare before, including Pharmaceutical Benefit Managers (PBMs), State Pharmaceutical Assistance Programs (SPAPs), and other prescription drug payers. CMS has worked with these new partners to educate them about coordination needs, to inform CMS about how the prescription drug benefit world works today, and to develop data exchanges that allow all parties to efficiently serve our mutual customer, the beneficiary.

COB Entities

Benefits Coordination & Recovery Center (BCRC) - The BCRC consolidates the activities that support the collection, management, and reporting of other insurance coverage for beneficiaries. The BCRC takes actions to identify the health benefits available to a beneficiary and coordinates the payment process to prevent mistaken payment of Medicare benefits. The BCRC does not process claims, nor does it handle any GHP related mistaken payment recoveries or claims specific inquiries. The Medicare Administrative Contractors (MACs), Intermediaries and Carriers are responsible for processing claims submitted for primary or secondary payment.

The BCRC is responsible for the following activities:

• Initiating an investigation when it learns that a person has other insurance. The investigation determines whether Medicare or the other insurance has primary responsibility for meeting the beneficiary's health care costs.
• Collecting information on Employer Group Health Plans and non-group health plans (liability insurance (including self-insurance), no-fault insurance and workers’ compensation), and updating this information on Medicare databases every time a change is made to insurance coverage. Information comes from these sources:  beneficiary, doctor/provider of service, employer, GHP, liability, no-fault and workers’ compensation entity, and attorney.
• Establishing MSP occurrence records on CWF to keep Medicare from paying when another party should pay first. The CWF is a single data source for fiscal intermediaries and carriers to verify beneficiary eligibility and conduct prepayment review and approval of claims from a national perspective. It is the only place in the fee for service claims processing system where full individual beneficiary information is housed.
• Transmitting other health insurance data to the Medicare Beneficiary Database (MBD) for the proper coordination of Rx benefits.
• Recovery of Non-Group Health Plan (NGHP) related mistaken payments where the beneficiary must repay Medicare. Please see the Non-Group Health Plan Recovery page for additional information.

Once the BCRC has completed its initial MSP development activities, it will notify the Commercial Repayment Center (CRC) regarding GHP MSP occurrences and NGHP MSP occurrences where a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity is the identified debtor. The BCRC will maintain responsibility for NGHP MSP occurrences where Medicare is seeking reimbursement from the beneficiary.   

When to contact the BCRC:

• To report employment changes, or any other insurance coverage information.
• To report a liability, auto/no-fault, or workers’ compensation case.
• To ask a general MSP question.
• To ask a question regarding the MSP letters and questionnaires (i.e. Secondary Claim Development (SCD) questionnaire.) For more information, click the Reporting Other Health Insurance link.

Please see the Contacts page for the BCRC’s telephone numbers and mailing address information.

Commercial Repayment Center (CRC) – The CRC is responsible for all the functions and workloads related to GHP MSP recovery with the exception of provider, physician, or other supplier recovery. The CRC is responsible for identifying and recovering Medicare mistaken payments where a GHP has primary payment responsibility. Some of these responsibilities include: issuing a Primary Payment Notice (PPN) to verify MSP information, issuing recovery demand letters when mistaken primary payments are identified, receiving payments, resolving outstanding debts, and referring delinquent debt to the Department of Treasury for further collection actions, including the Treasury Offset Program, as appropriate. Please see the Group Health Plan Recovery page for additional information.

The CRC will also perform NGHP recovery where a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity is the identified debtor. Please see the Non-Group Health Plan Recovery page for additional information.

Medicare Administrative Contractors (MACs) – A/B MACs and Durable Medical Equipment Medicare Administrative Contractors (DME MACs) are responsible for processing Medicare Fee-For-Service claims submitted for primary or secondary payment. These entities help ensure that claims are paid correctly when Medicare is the secondary payer. They use information on the claim form, electronic or hardcopy, and in the CMS data systems to avoid making primary payments in error. Where CMS systems indicate that other insurance is primary to Medicare, Medicare will not pay the claim as a primary payer and will deny the claim and advise the provider of service to bill the proper party.

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the [email protected] .

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

What is Coordination of Benefits?

Coordination of benefits (COB) refers to determining how multiple health insurance plans work together to cover a person’s medical expenses, ensuring that total payments do not exceed the actual cost of care.

Coordination of benefits must occur when a person holds multiple health insurance policies. If you have two plans, your insurers coordinate to determine which policy is the primary and which is the secondary. Coordination of benefits helps avoid duplicate expenses and keeps healthcare and prescription costs affordable for all policyholders .

Table of Contents

How common is double coverage.

Healthcare can be complex, and some people may need to enroll in multiple healthcare plans to cover all of their medical needs. It also may come as a matter of convince if both your and spouse have employer-provided care. 

Dual coverage through Medicare and a private or group insurer is especially common. More than half of  seniors age 65 or older  in the U.S. in 2021 held more than one health insurance policy, compared to only 6% of adults aged 19-64 that same year. 

Dual benefits are common among the following groups:

• Working couples who each have employer-sponsored health insurance
• People who are still working but are eligible for Medicare
• Someone who holds private insurance and is eligible for Medicaid
• A young adult who is on their parent’s insurance and an employer-provided plan

How Does the Coordination of Benefits Work?

COB applies to dual group coverage, Medicare and Medicaid , extended coverage such as COBRA , or dependent coverage when combined with another healthcare plan.

The coordination of benefits still largely follows the guidelines set by the National Association of Insurance Commissioners (NAIC) in 1971 including identifying a primary and secondary plan and using the “ birthday rule ” to cover dependents with double coverage. The birthday rule is for dependents who have coverage from both parents: the parent with the earlier birthday is the primary coverage, and the other parent is the secondary. 

Eligibility

You will experience coordination of benefits if you hold two different insurance plans. Eligibility for COB requires you to keep up on premiums for both plans. Additionally, you must adhere to each policy’s individual deductible , copay , and coinsurance terms. Always confirm your eligibility for each of the respective plans with an insurance agent. 

How Is the Primary Payer Determined?

The process of coordination of benefits follows certain universal guidelines to determine a primary and secondary plan. 

For example, Medicare typically acts as the primary payer if combined with another type of insurance, and the birthday rule applies to two employer-funded plans. Your healthcare provider can bill your secondary plan to pay the remainder of medical costs only after the primary plan pays its share. 

The rules on which insurer becomes the primary payer vary by situation, so it’s good practice to carefully review your policy terms and seek help if you need clarification. Understanding your coordination of benefits will ensure your healthcare costs are covered.

When Is the Coordination of Benefits Necessary?

The following are among the most common scenarios requiring coordination of benefits:

• You have employer-sponsored health insurance and are also covered by your spouse’s employer-sponsored plan
• You have health insurance through a private insurer and are also covered by your spouse’s group health insurance plan
• You and your spouse’s plans both cover your dependent child or children
• You receive Medicare and are also insured through your current employer   

Each scenario will have different ways of establishing the primary and secondary plans. It often looks like the examples below. 

The Methods of COB

A COB “method” is used to determine how your primary and secondary plans will share the costs of your medical coverage.

Full Method

Under the full method, the primary payer covers the claim as if you have no other insurance and applies the costs toward your deductible. After the primary payer has paid its part, the secondary payer determines its share of other out-of-pocket expenses, such as copays or coinsurance. Together, the two plans pay most or all of what your medical care costs. 

Non Duplication Method

The non duplication method requires the secondary payer to review claims paid by the primary payer. If the amount paid by the primary payer is equal to or more than the amount owed by the secondary payer, the secondary plan does not pay. However, the secondary plan will pay for applicable costs that the primary payer did not cover. 

Traditional

The traditional method of COB combines the coverage of multiple insurance policies to cover 100% of expenses. This process may require your insurers to work together to decide which will cover certain benefits on a case-by-case basis while still relying on select guidelines like the birthday rule. 

The Rules Around the Coordination of Benefits

Several ground rules exist to help govern coordination of benefits, explained below. If neither plan includes coordination of benefit rules, the plan providing coverage for a longer period pays first.  

• Employer-sponsored plans : Generally, your employer is the primary payer of your healthcare expenses, and your spouse’s plan is secondary if you both are enrolled in an employer health plan. 
• Medicare and Medicaid : Medicare acts as the primary payer if the other insurer is a business employing less than 100 people but is the secondary payer to the insurer of a large company. Medicaid typically only pays after the other insurer covers most of the costs.
• Private health insurance plan and Veterans Administration (VA) benefits : The VA charges health insurance providers for care and services instead of offering traditional health insurance coverage and does not offer secondary benefits. Your private health insurance would be the sole primary payer in this case.
• Workers’ compensation : If you receive both worker’s comp and traditional health insurance coverage, worker’s comp benefits always pay first, followed by your health insurance plan.
• Military coverage (TRICARE):  You may only have TRICARE coverage and no other health insurance benefits if you are on active duty; however, TRICARE is considered secondary to all other health plans, except Medicaid, for non-active-duty military service members. 

Determining Out-of-Pocket Costs

Insurers must determine how out-of-pocket costs are paid through COB. This process depends on whether your plans use the full COB method or the non duplication COB method. One of your insurers may cover out-of-pocket costs such as copays or coinsurance that remain after paying for services rendered.

Out-of-pocket costs include copays, or a set fee for doctor visits or prescriptions. Your secondary plan may pay copay costs after your primary plan applies its payment toward the deductible. Coordination of benefits must also be applied to other out-of-pocket expenses such as coinsurance or out-of-network providers, facilities, or prescription drugs.   

COB In Action

Your insurers must coordinate benefits if you have multiple health insurance plans. Common scenarios requiring COB include spouses with respective employer-sponsored plans, Medicare beneficiaries still working and receiving group healthcare benefits, and adults up to age 26 who buy their own coverage but also remain on their parent’s plan.

Insurers use various methods and rules to determine the primary and secondary plans. You should review your policies and speak with an expert to ensure you understand your coordination of benefits. 

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Employee Benefits

Coordination of Benefits (COB): What Is It & How Does It Work? 

In today’s diverse healthcare landscape, someone may opt for additional health insurance plans for various reasons, from access to a broader network of providers to help with reducing healthcare costs.

However, navigating benefits across multiple insurance plans can be tricky. That’s where coordination of benefits (COB) comes in. COB rules determine how multiple health insurance plans work together to pay an insurance claim for one person.

What is coordination of benefits?

Coordination of benefits is the process insurance companies use to determine how to cover your medical expenses when you’re covered by more than one health insurance plan. It clarifies who pays what by determining which plan is the primary payer and which is secondary. It also ensures proper claim processing and helps avoid overpayment or duplicate payments.

How does coordination of benefits work?

When a person has multiple insurance plans, COB rules determine the order in which the insurance plans will pay for covered services. The primary plan is responsible for processing the claim first and paying its share of the coverage amount. The secondary plan would then review the claim and pay the remaining balance within its coverage limits.

For example, suppose you visit your doctor and get billed $250 for the appointment. Your primary health plan may cover the majority of the bill. Let’s say, for example, that’s $200. Then your secondary plan would pay the remaining $50.

To prevent overpayment or duplication, plans will not pay more than 100% of the cost of the medical service(s), meaning that the combined benefits shouldn’t surpass the total cost of the treatment.

You may also be responsible for deductibles , copayments , and coinsurance.

Coordination of benefits examples

There are various scenarios in which someone might have two health insurance plans . Here are some everyday situations and how to determine which plan is most likely to be the primary or secondary payer.

Coordination of benefits rules

COB rules help organize and manage healthcare benefits and costs. Keep in mind that COB rules can vary depending on several factors, including the insurance company, the specific insurance plans involved, and the state you live in. Refer to the plan rules outlined in your policy and consult with your providers.

In general, the following COB rules will typically apply.

Policyholder or dependent rule

The plan for which you are enrolled as an employee or main policyholder will be the primary payer. The plan for which you’re enrolled as a dependent, such as a spouse’s plan, would be the secondary payer.

Birthday rule

This rule determines the order of coverage for children when both parents have health insurance. It places primary responsibility on the parent whose birthday falls earlier in the calendar year. The plan of the parent with the later birthday would have secondary responsibility.

Custodial parent rule

If parents are divorced or separated, the primary payer for dependent children would be the parent with child custody . However, if parents share joint custody, the order of benefits will typically follow the birthday rule.

Continuation coverage rule

If you have continuation coverage — such as the Consolidated Omnibus Budget Reconciliation Act (COBRA) — and coverage from another plan, the benefits of the plan covering you as a member or employee are primary. Your continuation coverage would be secondary.

Medicaid and Medicare rule

Let’s say you have coverage under a government program like Medicaid and Medicare in addition to other health or drug coverage. In that case, determining primary or secondary responsibility will depend on a number of factors. Factors can include your age, the size of the company you have employer coverage with, and other considerations. Check your insurance policy and coverage details or consult with your employer to determine what the order of coverage should be.

Timeline rule

If none of the above provisions determines which plan is primary, then the plan you've been enrolled in the longest is typically considered the primary one.

Potential drawbacks of using COB

Having multiple health insurance plans and coordinating benefits can be useful in the right situation, but in certain circumstances, the disadvantages of COB may outweigh the advantages. Here are some reasons why having multiple insurance plans and using COB may not be a favorable choice: Administrative complexity : Managing multiple plans and navigating COB can come with extra burdens, such as additional paperwork, coordination with multiple providers, and understanding the details of each plan’s rules and coverage.   Cost considerations: Maintaining more than one plan may not be a cost-effective choice if the combined premiums , deductible copayments, and coinsurance outweigh the benefits received.

Before enrolling in multiple health plans, analyze the cost-benefits and carefully review your coverage details to avoid surprises. Consult with your insurance provider(s) to determine the best approach for your unique situation.

Time to Enroll in a New Insurance Plan? 

Related reads.

1 “Is Medicare Primary or Secondary?” Medicare FAQ, 2023. 

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Coordination of Benefits

Tips for reducing payment delays and improving accounts receivable.

One of the major reasons for delays in claims processing is the need for information to support coordination of benefits. Coordination of benefits (COB) applies to a person who is covered by more than one health plan. The COB provision and regulations require that all health plans and other payers (e.g., Medicaid and Medicare) coordinate benefits to eliminate duplication of payment and assist patients to receive the maximum benefit to which they are entitled. By adhering to the COB provisions, the health plans and other payers can determine which plan will pay for a claim first.

The health plan or payer obligated to pay a claim first is called the "primary" payer and the other plan or payer is termed "secondary." Together, the primary and secondary payers coordinate payments for services up to 100% of the covered charges at a rate consistent with the benefits. When information about all potential sources of coverage is not available to plans and payers, claims will generally be "pended" and remain unpaid until complete COB information is on file.

Top reasons for COB-related delays in payment include: (1) incomplete or inaccurate COB information on file with the plan or payer, and (2) failure to attach the Explanation of Benefits (EOB) from the primary payer when billing the secondary payer. In addition, one of the leading reasons for claim denials is failure to submit complete and clean claims. The following tips are designed to assist physicians/providers and their billing staff to reduce payment delays attributed to COB-related problems:

1. Ask All Patients About Secondary Insurance Coverage

Have an office procedure to collect and/or confirm primary and secondary insurance information at each visit. Ask patients to provide the following information about their spouse and/or dependents: social security number; birth date; group/policy number for other medical coverage (if applicable); and Medicare or Medicaid ID card (if applicable). Collect this information at the time the appointment is booked to allow time for your staff to confirm eligibility prior to the visit.

2. Know What Plans and Payers Need to Pay Claims

Although each plan and payer may have slightly different requirements, there are some requirements that are nearly universal. For example, nearly all plans require a copy of the EOB from the primary payer prior to paying a claim as the secondary payer. Most plans and payers publish their requirements and the information should be available in physician/provider manuals, online and by contacting physician/provider representatives.

3. Determine Primary and Secondary Payers

It is important for physicians/providers to determine primary and secondary payers so that claims can be sent to the primary payer first. Some plans will be able to tell physicians/providers whether they are primary or secondary at the time the physician/provider contacts the plan to verify eligibility. Typically, the following rules are used by plans and payers to determine the primary and secondary payer:

• The payer covering the patient as a subscriber will be the primary payer.
• If the patient is a dependent child, the payer whose subscriber has the earlier birthday in the calendar year will be the primary payer. This is known as the Birthday Rule.

4. Attach EOB from Primary Payer When Submitting Claim to Secondary

Secondary payers must have a copy of the Explanation of Benefits (EOB) provided by the primary payer to process and pay a claim. Make attaching an EOB to claims filed with secondary payers a part of your routine office procedure.

A special consideration for Medicare claims

Many health plans receive Medicare claims automatically when they are the secondary payer. In this case, the Explanation of Medicare Benefits (EOMB) will indicate that the claim has been automatically crossed over for secondary consideration. Physicians/Providers should look for this indication on their EOMBs and should not submit a paper claim to the secondary payer. A paper claim submitted in this circumstance would be coded as a duplicate and rejected by the secondary payer.

A committee representing health plans and health care physicians/providers prepared this document. Organizations that participated in the development of this document include American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American Academy of Dermatology Association, Bethesda Healthcare System, Piedmont Hospital, Group Health Incorporated, and Health Alliance Plan. America's Health Insurance Plans and the Healthcare Financial Management Association convened the committee.

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.

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Coordination of Benefits & Third Party Liability

Related resources.

• Claims Under the Camp Lejeune Justice Act (CLJA)
• Medicaid Medical Support Requirements and Implementation Strategies Slide Deck
• Summary of Federal Statutory Requirements
• Summary of Federal Regulatory Requirements
• CFR Subpart D, Third Party Liability  
• Guide to Effective State Agency Practices 2014
• Guide to Effective State Agency Practices 2015
• Frequently Asked Questions
• 2020 COB/TPL Handbook

It is possible for Medicaid beneficiaries to have one or more additional sources of coverage for health care services. Third Party Liability (TPL) refers to the legal obligation of third parties (for example, certain individuals, entities, insurers, or programs) to pay part or all of the expenditures for medical assistance furnished under a Medicaid state plan. By law, all other available third party resources must meet their legal obligation to pay claims before the Medicaid program pays for the care of an individual eligible for Medicaid. States are required to take all reasonable measures to ascertain the legal liability of third parties to pay for care and services that are available under the Medicaid state plan. The Deficit Reduction Act of 2005 included several additional provisions related to TPL and coordination of benefits for Medicaid beneficiaries. For more information on Medicaid TPL and COB, see our  Frequently Asked Questions . For detailed information about COB/TPL policies, see our  2020 COB/TPL Handbook .

Coordination of Benefits

Coordination of Benefits (COB) refers to the activities involved in determining Medicaid benefits when an enrollee has coverage through an individual, entity, insurance, or program that is liable to pay for health care services. Individuals eligible for Medicaid assign their rights to third party payments to the State Medicaid Agency.

Examples of third parties which may be liable to pay for services:

• Group health plans
• Self-insured plans
• Managed care organizations
• Pharmacy benefit managers
• Court-ordered health coverage
• Settlements from a liability insurer
• Workers' compensation
• Long-term care insurance
• Other state or Federal coverage programs (unless specifically excluded by law)

Identification of Third Parties

States gather information regarding potentially liable third parties, including information about other sources of health coverage, when individuals apply for medical assistance. This information is periodically updated whenever a Medicaid enrollee's eligibility is renewed.    

Data Matching

States conduct data matches to identify third party resources. States must have laws in place that require health insurers to provide their plan eligibility and coverage information to Medicaid programs. For example, states conduct data matches with public entities, such as the Department of Defense, to identify Medicaid enrollees and/or their dependents that have coverage through the Military Health Services system and the TRICARE program. States also match with workers' compensation and state motor vehicle accident files. These matches can identify Medicaid enrollees that have sustained injuries which may be covered through workers' compensation or through an automobile insurance policy. State child support agencies are required to notify the Medicaid agency whenever a parent has acquired health coverage for child as a result of a court order.  

State Medicaid Programs and Use of Contractors for Data Matching

State Medicaid programs may enter into data matching agreements directly with third parties or may obtain the services of a contractor to complete the required matches. When the state Medicaid program chooses to use a contractor to complete data matches, the program delegates its authority to obtain information from third parties to the contractor.

Third parties should treat a request from the contractor as a request from the state Medicaid agency. Third parties may request verification from the State Medicaid agency that the contractor is working on behalf of the agency and the scope of the delegated work.

COB/TPL Guidance

• Guidance to State Medicaid Agencies on Dually Eligible Beneficiaries Receiving Medicare Part B Marriage and Family Therapist Services, Mental Health Counselor Services, and Intensive Outpatient Services Effective January 1, 2024 December 2023
• Third-Party Liability in Medicaid: State Compliance with Changes Required in Law and Court Ruling s April 2023
• Third Party Liability in Medicaid: State Compliance with Changes Required in Bipartisan Budget Act of 2018 and Medicaid Services Investment and Accountability Act of 2019 August 2021
• Notice of Proposed Rulemaking: Value-based Purchasing (VBP) and Drug Utilization Review (DUR) Proposed Regulation CMS-2482-P  June 2020
• CIB: Guidance for State Medicaid Agencies on Dually Eligible Beneficiaries Receiving Medicare Opioid Treatment Services December 2019
• Guidance to Medicaid Bipartisan Budget Act (BBA) of 2018 and changes to Medicaid Provisions Passed in April 2019 – Third Party Liability in Medicaid and CHIP  November 2019

Managed Care and Third Party Liability

The contract language between the State Medicaid agency and the Managed Care Organization (MCO) dictates the terms and conditions under which the MCO assumes TPL responsibility. Generally, TPL administration and performance activities that are the responsibility of the MCO will be set by the state and should be accompanied by state oversight.

There are four basic approaches to carrying out TPL functions in a managed care environment.  

• Enrollees with any other insurance coverage are excluded from enrollment in managed care
• Enrollees with other insurance coverage are enrolled in managed care and the state retains TPL responsibilities
• Enrollees with other insurance coverage are enrolled in managed care and TPL responsibilities are delegated to the MCO with an appropriate adjustment of the MCO capitation payments
• Enrollees and/or their dependents with commercial managed care coverage are excluded from enrollment in Medicaid MCOs, while TPL for other enrollees with private health insurance or Medicare coverage is delegated to the MCO with the state retaining responsibility only for tort and estate recoveries

MCOs and Data Matching

State Medicaid programs may contract with MCOs to provide health care to Medicaid beneficiaries, and may delegate responsibility and authority to the MCOs to perform third party discovery and recovery activities. The Medicaid program may authorize the MCO to use a contractor to complete these activities.

When TPL responsibilities are delegated to an MCO, third parties are required to treat the MCO as if it were the State Medicaid agency, including:

• Providing access to third party eligibility and claims data to identify individuals with third party coverage
• Adhering to the assignment of rights from the state to the MCO of a Medicaid beneficiary’s right to payment by such insurers for health care items or services
• Refraining from denying payment of claims submitted by the MCO for procedural reasons

Third parties may request verification from the state Medicaid agency that the MCO or its contractor is working on behalf of the agency and the scope of the delegated work.

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ADA Guidance on Coordination of Benefits

Coordination of Benefits takes place when a patient is entitled to benefits from more than one dental plan. Plans will coordinate the benefits to eliminate over-insurance or duplication of benefits.

General Coordination of Benefits Rules

It is important to note that only group (employer) plans are required to coordinate. So if one of the policies covering your patient is an individual policy, then it does not coordinate.

Employee/Main Policyholder - When both plans have COB provisions, the plan in which the patient is enrolled as an employee or as the main policyholder is primary. The plan in which the patient is enrolled as a dependent would be secondary.

Current Employment – When an employed patient has coverage through an employer that plan is primary over a COBRA or a retiree plan.

More than One Employer Plan – When a patient has plans provided by more than one employer, the plan that has covered the patient the longest is primary. A change in the dental plan carrier does not change the length of coverage time for the patient.

Dependent Children - The typical rules for dependents of parents with overlapping coverage rely on the birthday rule, that is, the parent with the earliest birthday in a calendar year is primary. In the case of divorced/ separated parents, the court's decree would take precedence.

Medical/Dental Plan – When a patient has coverage under both a medical and dental plan, the medical plan is primary.

Additional information regarding coordination of benefits that may be helpful follows.

Types of Coordination of Benefits

Many factors determine how COB is handled including state laws, processing policies of the carriers involved, contract laws, fully insured versus self-funded plans and types of COB utilized. There are several different types of COB that plans may use. A brief description of some of the more common methods follows.

Traditional - Traditional coordination of benefits allows the beneficiary to receive up to 100 percent of expenses from a combination of the primary and secondary plans.

Maintenance of Benefits - Maintenance of benefits (MOB) reduces covered charges by the amount the primary plan has paid, and then applies the plan deductible and co-insurance criteria. Consequently, the plan pays less than it would under a traditional COB arrangement, and the beneficiary is typically left with some cost sharing.

Carve out - Carve out is a coordination method which first calculates the normal plan benefits that would be paid, then reduces this amount by the amount paid by the primary plan.

Nonduplication COB - In the case of nonduplication COB, if the primary carrier paid the same or more than what the secondary carrier would have paid if it had been primary, then the secondary carrier is not responsible for any payment at all. Nonduplication is typically used in self-funded dental plans. A self-funded dental plan is a plan in which the plan sponsor bears the entire risk of utilization.

Self-funded plans are exempt from state insurance statutes and are generally governed by federal legislation known as the Employee Retirement Income Security Act (ERISA). In 2012, 49% of people with a dental benefit had a self-funded plan. 1 It is important that dental offices understand that not all patients will have a dental plan that is subject to your state’s COB laws. ADA policy opposes nonduplication provisions and at least one state, California, has enacted legislation prohibiting such provisions.

Network Plan Write-Offs

The difference between the dentist’s full fee and the sum of all dental benefit plan payments and patient payments is the amount of the write-off. Write-offs should not be posted until all plans have paid accordingly. If a write-off is posted after the primary pays and then posted again based on the secondary payment, it is possible the dental office may incorrectly apply a credit to the patients’ balance. Remember to always submit your full fee on the dental claim form.

Medicaid, Medicare and Coordination of Benefits

By law, all other available third party resources must meet their legal obligation to pay claims before the Medicaid program pays for the care of an individual eligible for Medicaid. 2 Thus, Medicaid is typically secondary to any other benefit plan.

In cases that involve a patient presenting with a retiree plan, Medicare and the patient has coverage on a spouse’s plan, generally any dependent coverage pays first, Medicare pays second and any non-21 dependent coverage (e.g. retiree coverage) pays third. 3

National Association of Insurance Commissioners (NAIC)

The NAIC has drafted model regulation on coordination of benefits and recommends that states pass similar legislation so that benefits can be coordinated uniformly across states. The ADA supports this also and recommends that state dental association’s attempt to pass similar legislation.

Affordable Care Act and its Impact on COB

Contrary to many myths, the Affordable Care Act did little to address claims submission and coordination of benefits (COB) arising from dental benefits embedded in medical plans and sold through the Federal and State Marketplaces. Thus, coordination of benefits and claims submission is handled the same as it was prior to the implementation of the Affordable Care Act.

The following information should help dental offices navigating the COB maze in the context of the ACA.

Billing to Medical Plans

Dentists will continue to submit the dental claim form along with Current Dental Terminology (CDT) codes to these plans. Even though the covered benefits are not necessarily the same as regular dental plans, the claims process remains the same.

Coordination of Benefits

For routine dental billing to two medical plans with embedded dental benefits, billing will be no different than it is now and any coordination should be attempted in the usual way (a determination of who the

1 NADP Purchaser Behavior Survey, September 2011 2 Accessed from: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/TPL-COB-Page.html 3 Model Regulation Service - October 2013, Coordination of Benefits Model Regulation, National Association of Insurance Commissioners, pg. 8.

primary payer is and then a copy of the explanation of benefits (EOB) statement submitted with the claim 1 to the secondary payer).

How is the primary coverage determined between a medical plan and a stand-alone dental plan? The usual primary coverage determination rules would apply. In California, Exchange contracts call for the embedded dental plan to always be primary and the standalone plan to pay secondary – this may vary by state. Keep in mind that some embedded plans may utilize a closed panel network meaning that benefits will only be paid if services are provided by a network provider. In this case and if the closed panel plan was primary, the secondary would basically provide coverage as though it were primary.

As in the past, it is strongly recommended that the dental office (assuming the office files claims on behalf of the patient) verify primary/secondary coverage by calling the customer service number on the patient’s identification card. If a dental office cannot determine which plan is primary, a call to the state insurance commissioner’s office could be made to determine primary versus secondary.

Contracting with Medical Plans

Medical plans with embedded dental benefits have indicated that they will not require dentists to be credentialed under the medical plan(s). Fees are determined by the dental plan and if a dentist is under contract with the plan, then contracted dental fees apply. If the dental office has questions regarding participating provider status, it is recommended that the office call the plan’s professional services department to obtain that information. Contact information for these departments can be found on the patient’s identification card.

Current ADA Policy on Coordination of Benefits

Guidelines on Coordination of Benefits for Group Dental Plans (Trans.1996:685; 2009:423)

When a patient has coverage under two or more group dental plans the following rules should apply: a. The coverage from those plans should be coordinated so that the patient receives the maximum allowable benefit from each plan. b. The aggregate benefit should be more than that offered by any of the plans individually, allowing duplication of benefits up to the full fee for the dental services received.

Navigating the path of coordination of benefits can be a frustrating and time consuming endeavor for dental offices trying to settle accounts for patients with more than one dental benefits plan. In addition, state laws and regulations often mandate coordination of benefits. If after the claim payment has been made and it appears to have been incorrectly adjudicated it is recommended that the claim determination be appealed and if necessary the state insurance commissioner’s office be contacted for assistance. This information along with state specific information on coordination of benefits, can be found by visiting the member’s only resource, Center for Professional Success website (success.ada.org) or you may call ADA staff at 800-621-8099 for further assistance.

Availity Tips: Coordination of Benefits, Vision, and Dental

Your feedback helps us make meaningful changes within Availity as quickly as possible. Here are some helpful reminders, thanks to questions we’re hearing from providers.

If you have new office staff who need Availity training, they can view the Premera  Availity Tips and Resources video tutorial  or check out our  user guide.

Availity also offers Premera-specific webinars in the Availity Learning Center. Simply  sign in to Availity , and go to the Availity Learning Center > Help & Training > Get Trained and enter the keyword “Premera.”

Coordination of benefits: I need to check the patient’s coordination of benefits (COB). Where can I find that in Availity?

If we know a member has other insurance, we’ll provide that information under the “Other or Additional Payer Information” section located below the payer logo that displays at the top of the page:

Looking up eligibility and benefits: Are there other options to look up eligibility and benefits? Is the only option to use the member’s ID number?

Yes, there are six different ways to verify a member’s eligibility and benefits. Under Member Search Options, you can choose from the following:

Visit limits for routine vision: Where do I find the visit limits for routine vision services?

If there’s a visit limitation, the limitation will display under the “Limitations” section of the benefit display:

Visit limits for physical therapy:  Where do I find the visit limits for physical therapy?

If it’s not listed, there is no visit limit. If there is a limited number of visits available, you’ll see it under the heading Limitations. Here are two examples:

Dental contact information: Where is the correct contact information for Premera Dental?

Check the back of member’s ID card. A copy of the member’s ID card displays under the Eligibility and Benefits Inquiry feature. Or go to the Premera Dental Payer Space > Resources > Contact Premera:

The Benefits of Professional Home Improvement Services

Whether you are dreaming of a kitchen, bathroom, or bedroom makeover or a complete home overhaul, professional home improvement services can take you from Pinterest to reality in no time.

There are a number of benefits of enlisting the expertise of professional home improvement professionals. Let's take a look at these benefits.

Expertise and Experience:

One of the most significant benefits of professional home improvement services is the expertise and experience they bring to the table. Professional service providers possess the knowledge, skills, and training necessary to execute complicated projects with precision.

They understand all of the nuances of construction, design principles, and building codes and will be able to ensure that your home improvement project is completed to the highest standards of quality and craftsmanship.

Customized Design Solutions:

Professional home improvement services offer customized design solutions that are tailored to your preferences, lifestyle, and budget.

Whether you're looking for something beautiful, hardy, or a mixture of both, experienced designers can work with you to create a plan that brings your vision to life while also meeting your needs.

They can help you with everything from space planning and material selection to color palettes and furniture arrangements. They will also help you source products that are within your budget. For example, if you're looking for help with re-flooring your home, visit this page .

Access to Quality Materials and Resources:

Professionals have access to a wide range of quality materials, products, and resources that may not be readily available to the average homeowner (they may even be able to get you a discount).

From high-end finishes and custom cabinetry to energy-efficient appliances and eco-friendly materials, professionals have a large network of suppliers and vendors, enabling them to source premium products at competitive prices.

Leverage their industry connections and expertise to help you select the best materials for your project. Ticking all of the boxes of durability, functionality, and aesthetic appeal.

Time and Cost Savings:

Having help from a professional can not only save you time, but in the long run, it can also save you on cost. Always remember, you get what you pay for so it might be worth spending a bit more up front to avoid issues in the future.

Experienced contractors and designers have the knowledge, tools, and resources to streamline the construction process, minimize delays, and avoid costly mistakes.

They can also help you navigate the complexities of permits, regulations, and inspections, ensuring that your project stays on track and within budget. They may even be able to give you advice on what to prioritize or spend money on to give you the best return on investment.

Project Management and Coordination:

Managing a home improvement project can be overwhelming and you may not know where to begin. It requires careful coordination of multiple different people and trades, schedules, and deadlines .

Having professional home improvement services takes the stress out of project management by overseeing every aspect of the renovation process, from initial concept development to final installation.

They act as a single point of contact for all stakeholders and will make sure that there is clear communication, accountability, and timely progress updates.

Attention to Detail and Quality Assurance:

When it comes to renovations, you have to pay attention to the details. Having a professional home improvement service can help with this as they pride themselves on their attention to detail and commitment to quality assurance, they will advocate for you and make sure everything is done correctly.

From precise measurements and flawless finishes to meticulous craftsmanship and installation, professionals always go above and beyond to ensure that every aspect of your project meets or exceeds your expectations.

Enhanced Property Value:

Renovating your home can have a significant impact on the value and appeal of your property. It will help to increase its marketability and resale value.

Renovations can yield a high return on investment, no matter whether you are looking to sell or whether you are just wanting to enjoy your “new and improved” home.

From kitchen and bathroom remodels to basement finishing and exterior upgrades, professional renovations can transform your home into a desirable and sought-after property that commands top dollar in the real estate market.

Professional home improvement services are worth paying for. They offer a number of significant benefits that can enhance the comfort, functionality, and aesthetic appeal of your home.

From expertise and experience to customized design solutions and quality assurance, professionals can contribute, knowledge and talent to your renovation project. By enlisting the services of experienced professionals, you can enjoy the peace of mind and satisfaction that comes from knowing your home is in capable hands.

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Coordination of benefits between the CDCP and Newfoundland and Labrador’s dental programs

April 2024 Version 1.0

This fact sheet is intended to provide information on the approach to coordination of benefits between the Canadian Dental Care Plan (CDCP) and the Newfoundland and Labrador's dental programs noted below.

Note: Individuals with private insurance are not eligible for the CDCP, and therefore there would be no coordination of benefits with the CDCP. Should clients have dental benefits through a private plan, then providers must not submit claims to the CDCP.

Program Name

Children’s Dental Health Program

Income Support Program

Low Income (Access) Program

Adult Dental Program

Administrator

Medical Care Plan (MCP) - Administration Office

Residents of the Avalon region: Phone: 709-758-1600 Residents of all other areas, including Labrador: Phone: 709-292-4000

What is the payer order between CDCP and Newfoundland and Labrador's dental programs?

The CDCP will be the primary payer relative to the Newfoundland and Labrador's dental programs.

How do providers submit CDCP claims to Sun Life?

Submitting claims under the CDCP will be done in the same way you are doing now with other insurance plans, so the process will be very familiar and easy.

Claims and CDCP client eligibility verification can be submitted through CDAnet, CDHAnet, and DACnet using oral health providers' existing Practice Management Software (PMS).

For more information on the claims submission process for CDCP, please consult the Sun Life claims submission information document.

Please note that before November 2024, the CDCP will only accept electronic claims submission through Electronic Data Interchange (EDI) . If a provider does not have EDI capability, they will be unable to seek reimbursement from Sun Life until November 2024 and will not be able to coordinate benefits with a secondary payer. Please contact the Newfoundland and Labrador's dental programs directly to discuss options.

How will the CDCP and Newfoundland and Labrador coordinate benefits?

Cob claim submission process - through edi:.

Where patients are eligible for CDCP and dental benefits under a Newfoundland and Labrador's program, providers will need to:

• Indicate in the patient's profile of their PMS that CDCP is the primary payer and the Newfoundland and Labrador's program is the secondary payer.
• The claim will automatically go to Sun Life first. Sun Life will generate an Explanation of Benefits (EOB) that will show the eligible amount covered under the CDCP ( Total Payable to Provider ).
• Make sure to indicate Pay to Provider, Assignment of Benefits , or equivalent (depending on the software) in your PMS - otherwise, your claim submission will be rejected by Sun Life. You will have to choose to assign benefits in your PMS and resubmit your claim.
• Providers will then need to send a claim to TeleClaim for any remaining amounts up to the MCP Dental Fee Schedules, and the claim will be processed according to the program policies. The EOB will not be immediately required to be submitted unless requested by MCP, but it should be kept for potential review.
• In cases where Newfoundland and Labrador's program fees are greater than CDCP fee rates, providers will be able to seek additional reimbursement from the Newfoundland and Labrador's program up to the Newfoundland and Labrador's program fee guide rates, through coordination of benefits . In cases where program fees are equal to or lower than CDCP fee rates, there will be no additional reimbursement on fees.
• Some services covered by the CDCP and by Newfoundland and Labrador's programs are subject to frequency limits. These frequency limits are not cumulative - neither the CDCP nor the Newfoundland and Labrador's programs will provide coverage for services beyond their respective frequency limits.
• CDCP clients will continue to be responsible for paying, directly to the provider, any applicable co-payment and any remaining amounts not covered by the CDCP and/or the Newfoundland and Labrador's dental programs.
• Providers must submit the EOB to MCP when requested by MCP adjudicators, either electronically or by paper in accordance with the existing process for the relevant Newfoundland and Labrador's program.
• Providers must submit claims to TeleClaim within 90 days of the date the service has been rendered, either electronically or by paper in accordance with the existing process for the Newfoundland and Labrador's programs.

More details concerning updates to the COB process effective November 2024 will be shared in the coming months.

What if services require preauthorization?

CDCP will start accepting requests for preauthorizations effective November 2024. There is no coverage under CDCP for services requiring preauthorization prior to November 2024 and there will be no coordination of benefits.

What else do providers need to know?

The COB process for CDCP and MCP will be the same as for other third party plans, with MCP remaining the payer of last resort.

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Long Term Care Coordinator

• Business Area: Clinical & Care Management
• Job Type: Full time
• Date Posted: May 09 2024
• Job Number: 1498343
• West Palm Beach, FL

Description

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose: Responsible for members gaining access to needed services through coordination and integration of medical and long term care services for the purpose of orientation, care plan development, assessment, and care coordination.

• Complete assessments with members, caregivers, or providers to obtain information regarding client status, support system, and need for services for care plan development
• Monitor delivery of services and follow-up with members, caregivers, or provider s through in person visits and telephonic contact
• Authorize and coordinate referral for services
• Ensure provider services are delivered without gaps and identify functional deficiencies in plans of care
• Assist in coordinating the development of informal or voluntary services to integrate into the member care plan
• Collaborate with discharge planners, physicians, and other parties to ensure appropriate discharge plan, care plan, and coordination of acute care and long term care services
• Assist member with filing and resolving complaints and appeals
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience: Bachelor’s degree or Registered Nurse License and 2+ years of care management experience, Licensed Practical Nurse and 4+ years of care management experience, or 6+ years of care management experience. Home health, discharge planning, or long term care experience preferred. Bilingual preferred.

Licenses/Certifications: Valid driver's license. LPN or RN preferred.

Location: Candidate must reside in Palm Beach County, FL.

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

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What Are the Benefits of Skipping Every Day?

Sport & activity.

From boosting heart health to decreasing anxiety levels, skipping can be an effective (and fun!) cardio exercise.

Skipping isn't just for kids. The exercise is versatile and often used as a warm-up or even as a key part of the workout itself.

Mike Matthews, ISSA - certified personal trainer and author of "Muscle for Life: Get Lean, Strong, and Healthy at Any Age!" says that skipping can fit seamlessly into just about any workout routine.

"You can skip at a slow, steady pace if you want to use it as low-impact, steady-state cardio or you can increase the intensity with techniques like high knees or double-unders (when the rope passes under the feet twice per jump), if you want to use it for HIIT-style training", he says. "Plus, if you're pushed for time and looking for an effective full-body workout, skipping is an excellent solution".

Not only can the repetitive movement of skipping elevate your heart rate, work muscles in the arms and legs, and burn calories, it may even provide a quick jolt of joy. If you find skipping to be a fun activity, you'll probably stick with it. A 2020 study published in the journal Frontiers in Psychology found that any form of physical activity someone considers enjoyable and stimulating can encourage them to work out more often.

And, skipping can also be a safe exercise for people of all ages. A 2018 meta-analysis of nine studies published in Sports Medicine found that up to three training sessions of skipping per week (where each session included three sets of 10 jumps per set, followed by 60 seconds of rest after each set) can enhance strength in adults over the age of 50. It's important to note, though, study participants didn't have any medical condition that could impair movement. Make sure you check in with your doctor to decide if skipping will be an effective exercise for your needs.

Before You Skip, Consider These Tips

If you haven't picked up a rope in a while, start with one that's the right length for your height .

"Stand on the middle of the rope with both feet, then grab a handle in each hand and lift them to chest height with your arms straight", says Matthews. "If the ends of the rope (the part where the rope meets the handle) reaches your armpits, the rope is the correct length".

Next, choose a solid surface to exercise on.

"Surfaces like concrete or tarmac can work, but they can also batter your joints if your sessions are long or you have ankle, knee, hip or lower-back problems", continues Matthews. "Ideally, do your workouts on a dense rubber or hard wooden surface, the kind you'd normally find in a gym, playground or tennis court".

RELATED: 5 Yoga Poses To Help Relieve Lower-Back Pain

In terms of mastering proper form while skipping, Stephanie Mansour, AFAA-certified personal trainer, ASFA-certified Pilates instructor, and host of the PBS show "Step It Up with Steph", recommends standing up tall and pulling your navel in towards your spine to engage your core.

"Hold the handles of the rope tightly, but not with a white-knuckle grip", she says. "As you jump with [either] single leg or double leg, land with a soft knee—meaning do not land with straight legs".

Instead, she says to bend at the knee so that the joints in your knee don't take on as much impact from the leg landing on the ground after each jump. Matthews adds that a common mistake is jumping too high.

"Stay on the balls of your feet and only jump about an inch off the floor each time. This makes the movement more efficient, along with helping to protect your joints and allowing you to skip for longer".

Keeping your jumps closer to the ground can reduce the force of the impact from each jump. Mansour also stresses the importance of taking it slow in the beginning and being kind to your body.

"I would advise that people start with just 60 seconds or 60 jumps", she says. "Also, when you begin skipping again, bear in mind that it's normal to get stuck and feel frustrated", and she assures you'll be back in the swing of things (literally) in no time.

5 Benefits of Skipping

1. skipping may boost heart health.

Several studies show that skipping is a highly effective way to improve cardiovascular fitness and lower blood pressure , says Matthews.

Physiotherapy researchers conducted a 2019 experimental study with young men where one group skipped twice a day for 12 weeks while the other group followed their usual exercise routine. As a result, the skipping group demonstrated statistically significant improvements in VO2 max (or maximal oxygen consumption, a measurement of how much oxygen the body uses during exercise).

Another 12-week, 2019 study in the European Journal of Applied Physiology found that skipping had a positive effect on numerous risk factors associated with cardiovascular disease including body composition, inflammation, blood pressure and vascular function (how blood and lymph circulates throughout the body) in teen girls with prehypertension.

2. Skipping Helps Improve Coordination

Italian scientific researchers gathered a group of preadolescent footballers and directed a portion of them to skip before training for a period of eight weeks. According to their findings, which were published in a 2015 issue of Journal of Sports Science & Medicine , the young athletes who skipped demonstrated better motor coordination and balance compared to their non-skipping teammates.

"Skipping improves balance and stability in the lower body", says Mansour. "The ankle and knee joints stabilise with every single movement".

The main reason: this exercise requires a lot of hand-eye coordination where the feet are learning how to make repetitive small and quick jumps. "Plus, the knees and the hips are working in conjunction with the ankle joints since the body works as a whole to jump repeatedly", she adds.

RELATED: Is Running Really That Bad for Your Knees?

3. Skipping Can Build and Maintain Bone Density

"Skipping has been shown to increase bone [mineral] density, which is particularly important for perimenopausal—transitioning to menopause—[people]", says Matthews.

A 2021 study observed young female Olympic swimmers who incorporated two new exercises into their routine twice a week: skipping and whole-body vibration (which involves sitting, standing or lying down on a vibrating machine). After 22 weeks, the swimmers' test results showed increased bone mineral density on the lumbar spine, hips and neck, along with a reduction in body mass in the lower body.

Furthermore, a 2015 randomised controlled trial in the American Journal of Health Promotion unveiled that women between the ages of 25 and 50 who skipped twice a day between 10 and 20 times (with 30-second rest intervals between each skipping session) saw significant gains in hip bone mineral density after eight weeks.

4. Skipping Increases Running Speed

Take note, runners. A meta-analysis of 21 studies published in 2021 identified a link between skipping and faster running times for distances between two and five kilometres (1.2–3.1 miles). More than 500 adults showed significant improvements in jump performance, sprint performance, reactive strength (a measurement of how high an athlete jumps after landing) and running economy (a measurement of multiple characteristics, such as cardiorespiratory and metabolic rate).

Additional research published in a 2020 issue of International Journal of Sports Physiology and Performance revealed similar findings. "Runners who warmed up with 10–20 minutes of skipping improved their 3K time significantly more than those who didn't skip to warm up", says Matthews. More specifically, the study subjects used a skipping rope two to four times a week to warm up for a total of 10–20 minutes each week, over the course of 10 weeks.

Don't miss 8 Warm-Up Exercises To Help You Prepare for Your Workout !

5. Skipping May Help Ease Anxiety

In order to find out if skipping has an impact on mental health, the authors of a 2021 study instructed a divided group of volunteers to skip for seven sessions where each session lasted two minutes—followed by one minute of rest. The results—which involved participants filling out a psychological questionnaire, taking a performance test and undergoing saliva and urine tests—revealed that adults who skipped showed significant reductions in anxiety scores and improved levels of attention span and cognitive function. The participants also showed higher levels of 5 - hydroxyindoleacetic acid in their urine, indicating a rise in serotonin (aka, a neurotransmitter associated with regulating mood and lowering anxiety).

When muscles contract during an activity, such as skipping, certain amino acids (branched-chain) circulating in your blood are necessary for the muscles to work, explains Elizabeth Lombardo, Ph.D., a licensed clinical psychologist and author of "Get Out of the Red Zone: Transform Your Stress and Optimise True Success".

"These amino acids are usually in competition with tryptophan—the precursor of serotonin—to cross the blood-brain barrier, meaning to enter the brain", she says. "So with less of these amino acids available, it increases the chance that tryptophan is picked up, which can result in an increase in serotonin in the brain".

The bottom line? Research suggests that skipping can provide different types of health benefits to a wide scope of people. If your doctor approves, consider adding a few minutes of skipping to your next workout—no matter what your goals are. Then, make sure you download the Nike Training Club App for more expert-backed advice and fitness tips!

Words by Amy Capetta

Move Daily with Nike Training Club

Get free guidance from trainers and experts to strengthen your body and mind.

Originally published: 5 May 2022

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