Coordination of Benefits, COBRA, & Appeals
Coordination of Benefits (COB)
| If you are enrolled in an HMO or Medicare Advantage (MA) plan, this section does not apply to you because those plan options will apply their own rules. You must obtain services under the terms of your HMO or Medicare Advantage (MA) plan in order for them to be paid. 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. For example, you may be covered by Trust coverage and by a spouse’s coverage from his or her current employer. In this instance, COB rules determine who pays claims first to ensure the same benefit is not paid for twice.Under COB rules, one plan is determined to be primary (processes your claims first) and the other as secondary. After the primary plan has paid, the secondary plan reviews any remaining balance to see if additional benefits are payable. All covered charges paid under the Trust are subject to COB rules. When you have more than one health care plan and the Trust is secondary, the primary plan pays first. The Trust may then pay up to the amount it would have paid if it were the only coverage. |
COBRA Continuation of Coverage
| If one of your dependents ages out or becomes ineligible for Trust coverage because of another qualifying event, there is no need to panic. Although your dependent will no longer be eligible under your Trust coverage, they may be able to continue coverage for up to 36 months though the COBRA (the Consolidated Omnibus Budget Reconciliation Act of 1985) Continuation Coverage option. A spouse and/or dependent children can elect and pay for COBRA coverage, which generally is the same health coverage they had the day before beginning COBRA. |
Claims & Appeals
| If you are enrolled in an HMO or Medicare Advantage (MA) plan, this does not apply to you. You must consult your HMO or Medicare Advantage (MA) plan for information on proper procedures for resolving claims and appeals. |
For prescription drug claims and appeals, visit the Prescription Drug Coverage page.