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Coordination of Benefits

All of the plans in the FEHB Program have Coordination of Benefits (COB) provision. This means that if you or a covered dependent have coverage under another group plan, your combined benefits will pay up to, but not more than, 100 percent of your covered expenses.

   How Coordination of Benefits Works   

One plan will be primary and pay benefits first. The other plan--the secondary plan--will make up the difference between the benefit paid by the primary plan and the actual allowable charge. If a plan does not include a COB provision, that plan will always be the primary plan and will pay benefits first.

When both plans have a COB provision, the following chart shows how the primary plan is determined for you and your spouse.

If a claim is for one of your dependents, the payment is based on the birth dates of the parents. This means that the plan of the parent whose birthday falls first in the calendar year will pay benefits first. The year of birth is not considered in determining payment order, only the month and day. If both parents have the same birthday, the plan that has covered the parent for a longer time will be primary.

If parents are divorced or legally separated, the plan of the parent with court ordered responsibility for health care expenses will pay benefits first. When a court order does not exist, the plan of the parent with custody will pay first.

If no other situation determines which plan pays first, the plan that has covered the person for a longer time pays first. However, an exception will be made for former or retired employees (and their dependents) who may have continued group coverage. In this case, the group plan for an active employee pays first, and the group plan covering the former or retired employee pays second.

  Coordination with Medicare  

The FEHB Program provides coverage for active employees age 65 or older and coordinates its coverage with Medicare. Medicare consists of two parts:

• Part A, which provides hospital insurance; and
• Part B, which provides medical insurance. Under current law, the FEHB Program and Medicare coordinate their benefits in the following way:
  • If you are age 65 or older and have Part A, your FEHB plan is the primary payer and Medicare is the secondary payer; and
  • If your spouse is age 65 or older and has Part A, Medicare is the secondary payer for your covered spouse, regardless of your age.