Double Coverage
Because many people covered by FEHB plans also have other health care protection, all FEHB plans have a coordination of benefits (COB), or double coverage, provision. The provision applies when a person covered by an FEHB plan is also entitled to benefits under any other kind of group health insurance, Medicare or no-fault or other automobile insurance that pays benefits without regard to fault. The purpose of the provision is to enable enrollees and covered family members to recover as much of their health care expenses as their total coverage permits, but not more than the actual charges for the care. Under COB, or double coverage, one plan normally pays its benefits in full as the primary payer, and the other plan pays a reduced benefit as the secondary payer. The combined amount paid by both plans will usually equal 100% of covered, or allowable, expenses.
Say, for example, that a person with double coverage is charged $100.00 for medical services received, that the actual charge is an allowable expense of both plans, and that the benefit of each plan is 80% of the allowable expense. Normally, the plan designated as the primary payer would pay $80.00, or its benefit in full, and the plan designated as the secondary payer would pay only the remaining $20.00.
Except for Medicare, primary and secondary payers are determined according to the guidelines of the Nationsil Association of Insurance Commissioners. Generally, the plan that covers you as an enrollee is the primary payer; the plan that covers you as a family member is the secondary payer.
The COB provision helps reduce the FEHB plan premium that you pay.
FEHB Plans and Medicare
Plans under the FEHB Program typically provide protection against the same kinds of expenses as Medicare, which has two parts (Part A, hospital insurance, and Part B, medical insurance). Under the law, d you're an employee age 65 or over and have Part A, your FEHB plan is the primary payer and Medicare is the secondary payer of benefits provided under both your plan and Medicare Part A or Part B. Medicare is also the secondary payer of mutually provided benefits for your covered spouse, regardless of your age, he or she is age 65 or over and has Part A.
**Note: After you retire, Medicare will become the primary payer and your FEHB plan will be the secondary payer for you (unless you are reemployed by the Government), and for your covered spouse (unless he or she is employed by the Government).
In addition, your FEHB plan is the primary payer and Medicare is the secondary payer of mutually provided benefits for an End Stage Renal Disease (ESRD) Medicare beneficiary under age 65 within the first 12 months of ESRI) care. Also, your FEHB plan is the primary payer anO Medicare is the secondary payer for a person under age 6 entitled to Medicare on the basis of disability.
FEHB Plans and Uniformed Services Health Benefits Program
If you are eligible for health care coverage under the Civilian Health and Medical Program of the Uniformed Service: (CHAMPUS), your FEHB plan is the primary payer of benefits, and CHAMPUS is the secondary payer.