Description | This tip provides data users with contextual information/definitions for the fields labeled coordination of benefits. Coordination of Benefits is a process used to determine which health insurance plan is responsible for paying a medical claim first when a person is covered by multiple health insurance plans. Below are some general rules that determine which insurance policy is primary when a person has two policies. Subscriber/member/dependent - If a person is subscribed to more than one plan, one as a member,
and the other as a dependent, then the plan in which they are subscribed to as a member would be the
primary insurance. The plan in which they are a dependent would be the secondary insurance. Actively employed vs retired/laid off/COBRA - If a person has been laid-off or retired, the plan they
were covered by before they retired or were laid off would be the primary plan, over the COBRA
continuation coverage or any state-mandated continuation of coverage. That coverage would be the
secondary insurance. Individual with two jobs - The full-time job is always the primary. If both are considered to be full-
time, then whichever plan they enrolled in first, will be the primary insurance. Spousal coverage - Their own insurance plan, through their own job, would be their primary
insurance, while their spouse’s plan would be the secondary insurance. Dependent children of parents who are not separated or divorced (birthday rule) - If a child is covered
by both of their married parent’s insurance plans, the child’s primary insurance is the plan covering the
parent whose birthday occurs earliest in the year. State and Federal Plans – Medicaid or Medicare is always secondary to a private insurance policy.
Resources: Coordination of Benefits | CMS Coordination of benefits - Glossary Coordination of Benefits & Third Party Liability | Medicaid |
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