UAW Retiree Medical Benefits Trust
Coordination of Benefits
When members of a family are covered under more than one plan, there may be duplication of coverage – two plans paying benefits for the same expenses.  The Coordination of Benefits (COB) rules determine who pays health care claims first when you or a family member are covered by more than one plan.  When someone is covered by more than one plan, one plan is primary and the other plan is secondary.  The primary plan processes claims first.  After the primary plan has paid, the secondary plan would review any remaining balance to see if additional benefits are payable.  All covered charges paid under the Plan are subject to Coordination of Benefits.  

The Plan may pay a secondary balance up to the amount the Plan would have paid if it were the only coverage.  Only covered charges under the Plan will be considered for payment under COB.  

If you are enrolled in an HMO or Medicare Advantage plan, this section does not apply to you, because the HMO or Medicare Advantage plan will apply its own COB rules.  You must obtain services under the terms of your HMO or Medicare Advantage plan in order for them to be paid.   

When you have more than one health care plan and the Plan is secondary, the primary plan pays first. The Plan may then pay up to the amount it would have paid if it were the only coverage.  

Rules of a Primary Plan Must be Followed

In general, you must follow the rules of your primary plan.  If you do not, and the primary plan denies a claim, then secondary coverage through the Plan will also be denied. 

RELATED LINKS

Coordination with Other Insurance Policies and Medicare
Subrogation and Reimbursement

COBRA Continuation Coverage

COBRA stands for the Consolidated Omnibus Budget Reconciliation Act of 1985.  COBRA is a federal law that gives certain eligible participants the right to continue health care coverage at group rates for a set period of time.  If a spouse or a covered family member should become ineligible for Plan coverage because of what COBRA refers to as a “Qualifying Event” (described below), he or she may be able to continue coverage for up to 36 months.  COBRA Continuation Coverage generally is the same health coverage the Dependents had the day before beginning COBRA Continuation Coverage.   

Note that a Same-Sex Domestic Partner who loses coverage under the Plan does not qualify for COBRA Continuation Coverage under the federal government’s COBRA regulations.  However, the Plan allows the Same-Sex Domestic Partner to continue coverage in the same manner as a spouse, as long as the opportunity is elected in a timely manner and the required Contributions are made; or if the Same-Sex Domestic Partner relationship ends, in the same manner as a divorced or legally separated spouse by making self-payments (in the same amount as the COBRA payment) for coverage for up to 36 months. 

Note: If you are enrolled in a Medicare Advantage plan, this section does not apply to you.

A spouse and/or dependent children can elect and pay for COBRA coverage for up to 36 months if they are no longer eligible for coverage under the Plan.

Additional information on Cobra Continuation Coverage

Claims and Appeals

This section addresses claims and appeals for services under the TCN or PPO plan options and the prescription drug benefit.  If you have a claim or appeal involving an HMO, Medicare Advantage, or other plan option, you should consult that Carrier’s booklet for the proper procedures for resolving claims and appeals.

RELATED LINKS:

How to File a Claim Notice of Claim Decision
Appeal Procedures Voluntary Review Process

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