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Understanding Coordination Of
Benefits (COB)

If You're Covered By More Than One Plan - Active Participants

You or your eligible dependentsAny dependent of a participant who meets the criteria for eligibility established by the Fund. may be covered by other group health plans, and this can result in duplicate coverage. The Administrative office should be notified when you or your dependents are covered by another plan. You should understand how your benefits are paid under these circumstances. Most group medical plans contain a provision explaining how payments of benefits from two plans are coordinated. Examples of other plans include your spouse's (opposite or same-sex) or dependent child’s medical plan or Medicare.* The (COB) rules ensure that a person is not reimbursed for more than the actual expense incurred for a medical service or supply.

The Fund's benefits were designed to help you pay your health care costs but not provide extra income through payments above your health care obligations. The goal is to cover your costs so that no more than the total of all services, subject to the R&CReasonable and Customary Charge - The fee regularly charged and received for a given service by the health care provider which doesn't exceed the general level of charges, as determined by the Fund, being made by providers of similar training and experience for treatment of a similar sickness, condition or injury in a similar geographic area. To determine an R&C charge, physicians are surveyed by region to determine what they will accept as payment for each procedure. That data is organized in percentile groups - the Fund uses the 80th percentile to determine R&C charges. limits or network contracted ratesThe fee that is negotiated between the plans and their network providers. Contracted rate applies to network services only. for eligible expenses will be paid. The Fund reviews and pays coordinated benefit claims based on the highest allowable charges, up to the greater allowable expense of either plan.

* Special rules apply when any covered individual is diagnosed with End Stage Renal Disease (ESRD) or other disabling condition eligible for Medicare benefits. See page 30 for additional information.

The Primary-Secondary Rule

The plan with the first obligation to pay the claim is called the primary plan, and the other plan is the secondary plan. Usually, the plan covering someone as a participant based on employment is the primary plan, and the plan covering someone as a dependent is the secondary plan.

Note: The Fund only applies COB to group health plans, not to individual polices. However, a plan is primary if it doesn't have COB rules.



Information Required

During the Open Enrollment period, the Administrative Office will ask you to update information about other group health coverage you and/or your covered dependents may have. A COB form will be included in the Open Enrollment package.

A request for COB information may occur in connection with a claim you've submitted. In that case, you will be advised that the other insurance information, including an Explanation of Benefit (EOB) statement from the other insurance carrier, is required before your claim can be processed.

Benefits paid when other insurance coverage exists are subject to the Plan's Coordination Overpayment Policy.


If Your Children Are Covered By More Than One Plan - Active Participants

If your eligible dependentAny dependent of a participant who meets the criteria for eligibility established by the Fund. children are enrolled in the Fund's medical plan and another group plan (such as your spouse's opposite or same-sex plan at work), the Fund uses the birthday rule to determine which plan pays benefits first. Under this rule, the plan of the parent whose birthday occurs earliest (month and day) in the year is the primary plan for dependent children. If both parents have the same birthday, the primary plan is the one that has covered a parent longer.

Note: If we do not have COB information on the first claim received on a dependent child, where the spouse's birthday occurs earliest, claims may be delayed until the required COB information is received.

When the Fund's medical plan is secondary, the Fund's payment will be limited so that the total payment from the primary plan and the Fund's plan is not more than what the Fund's plan would have paid if it had been the primary plan. However, the Fund reviews and pays coordinated benefit claims based on the highest allowable charges, up to the greater allowable expense of either plan.

If two or more plans cover a person as a dependent child (under 26 years old) of divorced or separated parents (whether or not they were ever married), benefits for the child are determined in this order:

  • The plan of the custodial parent pays first;
  • The plan of the custodial parent's spouse pays second; and
  • The plan of the non-custodial parent pays third.

If the divorce settlement specifies otherwise, a copy of the court order is required, and the Fund will follow the court order. The primary-secondary rules.

Note: The COB rules above applies to the pharmacy program and the dental plans. In the Summary Plan Description, see this page for the specific COB rules that applies to your prescription drug coverage, this page for the DPO Plan and this page for the DHMO Plan.

Other COB Rules
  • A plan that covers you as an active participant is primary to a plan covering you as a participant receiving benefits under a severance plan or as a retiree.
  • A plan that covers your dependent while you are an active participant is primary to a plan covering your dependent while you are a participant receiving benefits under a severance plan or a retiree.
  • If none of the above rules determines the order of coverage, the plan that covered the participant longer is primary.
  • If none of the above applies, the plan will coordinate payment with the other plan.

If the Fund pays benefits as the primary plan, it pays without consideration of what the secondary plan pays or does not pay.

If the Fund pays benefits as the secondary plan, it determines:

  • What it would have paid if there had been no other group coverage; and
  • What the primary plan has paid or will pay.

The Fund then pays the difference between the total charge for eligible expenses Any reasonable and customary charge for medically necessary services or supplies which is covered in full or in part by the plan.and the amount paid by the primary plan, within the maximums and limitations of the Fund's plan.

Claim Example:  Let's say you need a minor operation that will cost $1,200, which is within R&C limits. Let's also assume your individual calendar-year deductible The portion of eligible expenses you're responsible for paying each calendar year before the Fund begins to pay certain benefits. is $300 and your non-network coinsurance The percentage of eligible expenses you're responsible for paying. rate is 70% of R&C. Here's how the COB process would pan out based on the primary-secondary rule:

You must notify the Administrative Office as soon as you add or lose other group health coverage.

If The Fund is Primary. . . If The Fund is Secondary. . .
Eligible expenses
$1,200
Eligible expenses
$1,200
Deductible
- $ 300
Primary plan paid
- $ 700
Non-network coinsurance
$ 900
  x 70%
Fund pays
 
$ 500 
Fund pays
$ 630    

COB Checklist

Before enrolling in or dropping coverage under any plan, consider the following:

  • Which plan is considered my primary plan under each plan's coordination of benefits rules?
  • What rules does each plan follow if another plan should be considered primary?
  • Are there benefits if health coverage is provided under multiple plans for me or my dependents?

Administration of COB

To obtain all the benefits available to you, you should file a claim under each plan that covers the person for the expenses that were incurred. However, any person who claims benefits through the Fund must provide the Administrative Office with all the information the Fund needs to apply the COB rules.

To administer the COB provision, the Fund reserves the right to exchange information with other plans involved in paying claims, require that you or your health care provider furnish any necessary information, reimburse any plan that made payments that this Fund should have made, and recover any overpayment from your hospital, physician, dentist, other health care provider, or other insurance company for you or your covered dependent.

If this Fund should have paid benefits that were paid by any other plan, this Fund may pay the plan that made the other payments in the amount the Fund determines to be proper under this provision. Any amounts paid will be considered to be benefits through this Fund and this Fund will be fully discharged from any liability it may have to the extent of such payment.

If your personal information has changed — for example, if you've gained other insurance coverage — you must contact the Administrative Office to update your records. See our website at www.wgaplans.org to access the COB form. You will need to click on the "Forms" tab displayed under the Health Fund menu, and then on the "Coordination of Benefits" link.

If You're Covered By More Than One Plan - Certified Retirees

If you are a participant who retired with Certified Retiree status after March 1, 1997, or you are a participant who retired with Certified Retiree status on or before March 1, 1997 and you are receiving a benefit from the Producer - Writers Guild of America Pension Plan in the amount of $800 or more per month, when you become eligible for Medicare, the Fund coordinates your benefits with Medicare so that the combined medical payments of Medicare and the Fund are equal to but not more than what the Fund would have paid if Medicare were not involved. Surviving Spouses (opposite or same-sex) or Same Sex Domestic Partners of such Certified Retirees, upon becoming eligible for Medicare, will then have their medical benefits coordinated with Medicare in the same way.

Claim Example: If you're enrolled in the PPO Plan, you've met your individual calendar-year deductibleThe portion of eligible expenses you are responsible for paying each calendar year before the Fund begins to pay certain benefits. and you have eligible expenses of $2,300. Let's also assume that under the Fund, network coinsurance is 85% and non-network coinsuranceThe percentage of eligible expenses you're responsible for paying. is 70% of R&C.

If you’re a participant who retired with Certified Retiree status on or before March 1, 1997 and you’re receiving a benefit from the Producer - Writers Guild of America Pension Plan of less than $800 per month, when you become eligible for Medicare, the Fund coordinates your benefits with Medicare with the method that was in effect on April 1, 1997. This approach allows for reimbursement up to 100% of the Medicare allowed amount (an example of this COB calculation is presented in the table located at the top of page 53, under the section titled: “Other COB Rules”). Surviving Spouses (opposite or same-sex) or Same Sex Domestic Partners of such Certified Retirees, upon their becoming eligible for Medicare, will then have their medical benefits coordinated with Medicare in the same way.

PPO PLAN
 
Network Provider
Non-network Provider
Eligible expenses
Assume Medicare pays first
Balance before the Fund pays
$ 2,300
- $ 1,610
     $690
$ 2,300
- $ 1,610
     $690
Maximum the Fund would pay if it were primary plan
$2,300 x 85%
= $ 1,955
$2,300 x 70%
= $ 1,610
Medicare payment
Amount the Fund Pays
- $ 1,610
     $ 345
$ 1,610
     $ 00
Balance after the Fund pays
Amount you pay
$ 345
$ 345
$ 690
$ 690


Important!

Participants entitled to benefits under Medicare, whether or not they enroll will be deemed to have enrolled for purposes of determining which plan is primary and what benefits are payable by the Fund.



Important!

If your provider accepts Medicare assignment, the plan will consider up to the Medicare-allowed amount.