Coordination of Benefits

Coordination of Benefits (COB) is the method of dividing responsibility for payment among group health plans that cover an individual so that the total of all covered expenses will be paid.

Primary Plan

The primary plan is the plan that pays first on the claim. If a balance is still due after the primary plan’s payment, the secondary plan will consider the claim. In determining which of the plans is primary or secondary, this Plan will apply the following rules. The first rule that applies to the situation will be used:

1. The plan covering the person as an employee is primary to the plan covering the person as a dependent.
2. When both plans cover a child as a dependent, the plan of the parent whose birthday (using month and day of birth) falls earlier in the year pays first. If both parents have the same birthday, the plan that has covered the child for the longer period of time is primary. This is called the “birthday rule.” See special rules below for children of divorced parents.
3. The plan covering the person as an active employee (or that employee’s dependent) is primary to the plan covering the person as a retired employee.
4. The plan covering the person for the longest continuous period is primary to the plan covering the person for a shorter continuous period.

Children of Divorced Parents

With a QMCSO

If one of the parents is required by a Qualified Medical Child Support Order (QMCSO) to provide health care coverage for the child, the plan of the parent who is responsible for coverage as ordered by the court is primary. The plan of the other parent is secondary.

Without a QMCSO

• The plan of the parent with custody is primary, the plan of the step-parent (if any) with custody is secondary, and the plan of the parent without custody is third.
• If the parents were awarded joint custody, the “birthday rule” outlined above applies.

Coordination of Benefits under COBRA Continuation Coverage

If an individual is covered by this Plan or another plan under a COBRA provision, the following coordination of benefit rules apply:

• The plan covering the person as other than a qualified beneficiary under COBRA (or a dependent of a qualified beneficiary) pays primary to the plan covering the person as a qualified beneficiary.
• When both plans cover the person as a qualified beneficiary under COBRA (or a dependent of a qualified beneficiary), the plan which has covered the person for the longer period of time is primary to the plan covering the person for the shorter period of time.

Coordination of Benefits With Medicare – Active Employees and Spouses

When you or your spouse continues to work after age 65

Medicare has special rules that apply to Medicare beneficiaries who are older than 65 and who have group health coverage through their own employment or the employment of a spouse. In such situations, Medicare will give you and your spouse the option to accept or reject coverage with the Fund.

If you accept coverage through this Fund, the Fund will provide benefits as the primary plan and Medicare will be the secondary payer.

If you reject coverage through this Fund, Medicare will be the only health insurance payer. The Fund will provide NO benefits.

When you have Medicare because of kidney disease

If you are entitled to Medicare solely because of end stage renal disease (ESRD), the Fund is required to provide benefits as the primary plan for 30 months during which time Medicare will be the secondary payer. When the 30-month period is over, Medicare will provide benefits as the primary plan and the Fund will be secondary.

When you are covered by the widow/widower self-payment plan and turn 65

When a widow/widower reaches age 65, he or she will be covered by the Fund’s Retiree Plan and Medicare will become the primary plan.

Coordination of Benefits With Medicare – Retired Employees and Spouses

When you or your dependent spouse reaches age 65, you or your spouse are eligible for Medicare benefits. At that time, if you enroll in a Medicare Advantage Plan, that plan will become your primary and only plan. No additional benefits are provided by the Fund. If you are enrolled in the Operating Engineers PPO Plan, Medicare will become your primary plan and the Operating Engineers PPO Plan will become secondary. The maximum allowance on any claim involving Medicare will be the amount approved by the Medicare Advantage Plan.

Medicare Enrollment

You must enroll in Medicare in advance of age 65 to avoid a reduction in coverage.

Medicare enrollment is NOT automatic unless you have filed an application and establish eligibility for a monthly Social Security benefit. If you have not applied for Social Security benefits, you must file a Medicare application during the three-month period prior to your 65th birthday in order for Medicare benefits to begin during the month you reach age 65. Call or write the nearest Social Security Office at least 90 days before your 65th birthday and ask for an application. You can also apply online at: www.ssa.gov/medicare.

Medicare Claims

In most cases, Medicare will forward this information directly to the Fund on your behalf. In the event Medicare doesn’t forward the information on your behalf, you or your provider must submit the Medicare Explanation of Benefits (MEOB) along with the complete itemized bill to Anthem Blue Cross or payment cannot be made. The Fund cannot provide benefits on your claims without a MEOB. This is the notice Medicare will send to you which shows what services were covered, what charges were approved, how much was credited to your deductible and the amount Medicare paid for each service.

You or your provider should mail the itemized bill and the MEOB to:

Anthem Blue Cross
P O Box 60007
Los Angeles, CA 90060-0007

Questions About Medicare

If you have any questions or need information regarding Medicare in general, Medicare Health Plans, etc., please contact Medicare directly at (800) MEDICARE or (800) 633-4227 or go to www.cms.gov.