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Answers to Frequently Asked Questions (FAQs) - Coordination of Benefits

To learn about coordination of benefits between OEBB plans and Medicare, please visit the Medicare FAQ page.
 
 
When an OEBB member has dual OEBB coverage, does the deductible have to be satisfied or will it be picked up by the other plan?
The deductible still must be satisfied prior to any benefit reimbursement.  For example, if a member is dual covered under OEBB medical Plan 3, there is a $100 deductible that must be met. The following is an example of how this would work: ODS receives a claim with eligible charges of $120; $100 is applied to the primary plan's deductible. ODS would reimburse the provider 90 percent (assuming the service was in-network and not a copayment service) of the remaining balance of $20, which equals $18. ODS would then apply the same $100 to the secondary coverage's deductible. ODS would pick up the additional $2 of eligible charges, which was not applied to the deductible, as the secondary carrier. Total member responsibility for this claim - $100.00. Deductible is now satisfied on both plans.
Coordination of benefits (COB) is confusing. Can you provide some examples for dual coverage with medical plans so I can get a better understanding of how benefits will be coordinated?
In most cases, once the deductibles are satisfied, the member will not have any further out of pocket expenses, unless limitations and/or maximums are met. If you seek services from out-of-network providers, you will be responsible for any charges in excess of the ODS maximum plan allowance (MPA). If you have secondary coverage through a non-ODS plan, please check with that plan’s insurance carrier on how they handle coordination of benefits. Please see below for sample scenarios.
Example #1
An ODS member has dual medical coverage. The primary coverage is through ODS. The member is covered under OEBB Plan 3 with a $100 individual deductible/$300 family deductible. The secondary coverage is through the member’s spouse, ABC company, with a $500 individual deductible/$1,000 family deductible. The first $100 in eligible charges would apply to both deductibles. Once the $100 deductible is met on the OEBB/ODS plan, ODS would begin to pay benefits. Eligible charges would continue to apply to the secondary plan’s $500 individual deductible, until it is met. Once the secondary’s plan deductible is met, the primary plan (ODS) would pay its normal benefits and the secondary plan would pay the remainder, leaving a zero dollar balance to the member in most cases.
Example #2
A married couple has dual coverage under an OEBB ODS plans. The member for the example below has OEBB Plan 7 as primary and OEBB Plan 3 as secondary. The member goes to the doctor for an in-network office visit. If the charge for the visit is $200, Plan 7 applies $200 toward the deductible and pays nothing to the provider. Plan 3, as the secondary plan, pays $190 to the provider (total office visit cost less the $10 copayment). The member now has met $200 of Plan 7 deductible, $0 of Plan 3 deductible and pays the $10 copayment to the provider. The member goes for another in-network office visit. This time the charge is $350. Plan 7 applies $300 toward the deductible, and then pays 80 percent of the remaining $50 ($40). Patient responsibility under Plan 7 would be $310 (remaining deductible + coinsurance of 20 percent). Plan 3, as the secondary plan, would pay $340 if it were the only plan in place (total office visit cost less the $10 copayment), but since the patient responsibility is $310 after plan 7 has been applied, Plan 3 would pay the balance of $310. The member has now met the $500 Plan 7 deductible, but has not yet met any deductible on Plan 3.


Need more information? Review more Frequently Asked Questions.