Sometimes you might have benefit coverage under more than one health plan, typically through your spouse’s employer. In these cases, you can submit the expense under both plans to get up to 100% of your expense covered. This is called coordination of benefits (COB).

With coordination of benefits, you claim first with the plan you are the main member of, then you claim any amount that was not reimbursed through your spouse’s plan.
If you and your spouse both pay premiums to participate in a benefit plan, you may be tempted to save on payroll deductions by opting out of your spouse’s plan. However, coordinating the benefits provided by each plan can save you money, in most cases providing coverage up to 100% of the expense. Saving you from out-of-pocket expenses related to health care costs is what your benefit plan is designed to do.

Understanding COB

Jonathan’s plan covers his acupuncture treatment ($100) at 80% coinsurance. Jonathan’s wife Alexis has a plan that also covers acupuncture at 80%. If Jonathan only had his own coverage, he would be reimbursed $80 and would be out of pocket for $20. But since he also has coverage through his wife, he submits his explanation of benefits (EOB) from his insurance to his wife’s plan, and he can claim the remaining $20 for reimbursement through that plan.

Which plan should you claim under first?

You should make your claims through your employer’s coverage first, and then your spouse’s plan. Your spouse should claim through their employer’s coverage, and then yours. Things can get a little confusing when submitting claims for children. The plan that pays first is determined by the birth date of the parents. The plan for the spouse whose birth date is earlier in the calendar year is the first payer, and the plan for the spouse with the later birth date pays second.

If you have questions regarding COB, please contact us and we are happy to assist you.