Coordination of Benefits
It’s important to keep PEHP and any other insurance carriers informed when you or another family member add or lose insurance coverage. This helps ensure your claims are being processed correctly and helps you avoid unnecessary charges. Fill out the Duplicate Coverage Inquiry Form to report other coverage or changes in coverage.
How We Determine the Order of Benefits
When you’re covered by two or more insurance plans, PEHP uses state guidelines to determine which portion of your claims each plan pays. This is called coordination of benefits. The primary carrier covers the major portion of eligible bills, and the secondary carrier may cover any remainder.
|Situation||Which Plan is Primary||Which Plan is Secondary|
|You’re insured through your employer and your spouse’s employer.||Your employer’s plan is primary for your claims, and your spouse’s employer’s plan is primary for his/her claims.||Your spouse’s plan is secondary for your claims, and your plan is secondary for your spouse’s claims.|
|Your dependent children are covered by both natural (married) parents.||The plan of the parent whose birthday comes first in the year (month/day).||The plan of the parent whose birthday comes second in the year.|
|You and your spouse are divorced and both maintain coverage for your children under age 18.||The plan of whichever parent is ordered to maintain coverage by the divorce (or other legal) decree. If the coverage for the household of the ordered parent is provided by his/her spouse, that coverage is primary in lieu of the natural parent’s plan.||The non-ordered parent’s plan. If the coverage in the household of the non-ordered parent is provided by his/her spouse, that coverage is secondary in lieu of the natural parent’s plan.|
|You and your spouse are divorced and both maintain coverage for your children over age 18.||The plan of the parent with whom the child resides (or the step-parent in that household, if he/she provides the insurance coverage). If the child lives with neither parent, the plan that has been covering the child the longest is primary.||The plan of the parent with whom the child does not reside (or the step-parent in that household, if the step-parent provides the insurance coverage). If the child lives with neither parent, the plan that has been covering the child the shortest length of time is secondary.|
|You and/or your spouse (married or divorced) cover an adult child who is also covered under his/her own spouse.||The plans will coordinate in order of length of continuous coverage*. The plan that has been in place longer is primary.||The plans will coordinate in order of length of continuous coverage*. The plan that has been in place shorter is secondary.|
|You are covered through your former employer as a retiree and your spouse also covers you through his/her employer.||Your plan will remain primary for you, and your spouse’s plan will be primary for him/her.||Your spouse’s plan will be secondary for you and your plan will be secondary for your spouse.|
|You are over 65 and covered through your employer or your spouse’s employer and also covered by Medicare.||If the employee providing the coverage is actively working and his/her employer has more than 20 employees, that plan is primary. If the group has less than 20 employees, Medicare is primary.||If the employee providing the coverage is actively working and his/her employer has more than 20 employees, Medicare is secondary. If the group has fewer than 20 employees, the employer’s plan is secondary.|
|You have two coverages through either active employment or retiree coverage and are the policy holder on both plans.||The plan that has been in effect longer (continuously*) will be primary.||The plan that has been in effect the shortest will be secondary.|
*Note: “continuous coverage" refers to coverage via the same sponsor with no break of 24 hours or more. If your employer changes carriers with no break in coverage, that is still considered “continuous.”
If you’re covered by two or more insurance plans, carefully consider your network choice to maximize the benefits of the combined plans. In most cases, when the services you receive are in-network on both plans, you get a better combined benefit.
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