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COB Canadian Life
COB Canadian Life
COB Canadian Life
COORDINATION OF BENEFITS
This Guideline has been approved by CLHIA's Board of Directors. All member companies are expected
to comply with the CLHIA Guidelines. Companies are urged to bring Guidelines to the attention of their
Board of Directors or the Board Committee responsible for the company's compliance program with a
view to incorporating the Guidelines into the company's ongoing compliance program.
INTRODUCTION
The Coordination of Benefits Guidelines were developed for insurers to ensure
consistency within the industry in situations where a person can submit a claim to more
than one group plan. They are divided into two parts: Part A: Group Dental and Health
Benefits; and Part B: Out-of-Country/Province Health Care Expenses.
PURPOSE
These Guidelines describe how to coordinate either dental or healthcare payments from
all group plans under which a person is covered, so that total payments do not exceed
total eligible expenses.
Plan is defined as group insurance or any other arrangement of coverage for
individuals in a group, whether on an insured or an uninsured basis, including any
prepayment coverage or capitation plan, as long as the group is not formed solely for
the purpose of obtaining insurance. This definition of plan does not include school
insurance or individual travel insurance.
2
ELIGIBLE EXPENSES
Payment on a particular claim cannot exceed 100% of the eligible expenses. Eligible
expenses are as defined in each carriers contract/plan document before payment
limitations like the deductible, co-insurance, lagging fee guides and/or maximums are
applied. In the case of dental, 100% of eligible expenses will be the appropriate
general practitioners or specialists current fee guide.
Each carrier adjudicates the claim taking into account reasonable and customary
charges, maximums and contractual fee guide limits in the normal fashion.
3
The plan that determines benefits first (primary carrier) will calculate its benefits as
though duplicate coverage does not exist.
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The plan that determines benefits second (secondary carrier) limits its benefits to the
lesser of:
(i)
The amount that would have been payable had it been the primary carrier, or|
(ii)
100% of all eligible expenses reduced by all other benefits payable for the same
expenses by the primary plan.
This means that an individual may receive reimbursement for up to 100% of the eligible
expenses.
(Examples for dental and health claims are included in Appendix A for clarification.)
(1)
(2)
If the other plan(s) has a Coordination of Benefits provision, priority goes to the
plan in the following order:
Employees/members
(i)
(ii)
(b)
(c)
Dependents
Spouse
(iii)
Dependent Children
(iv)
The plan of the parent with the earlier birth date (month/day) in the
calendar year.
(v)
The plan of the parent whose first name begins with the earlier letter in
the alphabet, if the parents have the same birth date.
(vi)
(b)
the plan of the spouse of the parent with custody of the child,
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(c)
(d)
Dental Accidents
For dental accidents, health plans with dental accident coverage determine
benefits before dental plans.
Other Situations
If priority cannot be established in the above manner, the benefits will be prorated in proportion to the amounts that would have been paid had there been
coverage by just that plan.
5
ADMINISTRATIVE PROCEDURES
The primary carrier will provide the claimant with a complete explanation of benefits
(EOB) with service details, charges and amounts paid for the second carriers
assessment. The second carrier will not require the original claim form if a copy is
provided.
It is the claimants responsibility to retain a copy of the original claim form to apply for
the coordination of benefits provision.
It is up to the discretion of each carrier to adjust overpayments made by the first
payor.
6
The coordination of benefits between capitation and fee-for-service dental plans shall be
determined in the same manner as between fee-for-service plans.
The order of benefit determination (OBD) remains unchanged and the primary and
secondary carriers are determined by applying the OBD rules already outlined in the
CLHIA Guidelines.
If a person with dual insurance coverage is insured under a capitation plan and is
treated by a dentist who is a member under that plan, priority is established by
following the order of benefit determination.
When one of the dental plans is a capitation or prepaid dental plan, all insured
individuals must attend the participating dental offices in order to be entitled to the
Coordination of Benefits provisions.
If the insured individual attends a nonparticipating dental office, there will be no coordination of benefits with the capitation
plan since the capitation plan would not reimburse the fee-for-service carrier or the
insured for any expenses incurred. This is considered a fundamental principle of
capitation plans.
Capitation companies audit the dental services provided by their practitioners and they
consider the COB payment as part of the dentists payment when they establish the
capitation fee.
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When the capitation plan is primary, the dentist may collect the co-payment from the
secondary plan by assignment or directly from the patient.
When the capitation plan is secondary, the dentist should receive the payments from
the primary plan, but the dentist must waive the patients capitation plan co-payment.
(If the primary plan pays less than the co-payment, the patient will be required to pay
the difference.)
PURPOSE
These Guidelines for insurers have been developed to encourage consistency within the
industry in claim situations where a person has travel health insurance coverage from
more than one policy (for example, from employment-related group insurance
contracts, individual or group travel or health policies, credit cared coverages or any
other private insurance sources).
It is necessary to establish guidelines since many contracts for these benefits contain a
provision that indicates that they will be last payor after claim payment has been made
under all other contracts, and often it is not readily apparent which contract should pay
first.
These Guidelines describe how to coordinate the payments from all such policies under
which an individual is covered, so that the total payments from all policies do not
exceed the total expenses incurred or, in the case of cash policies, do not encourage
multiple purchases. The intent is to establish a streamlined adjudication process that
allows for effective claim management; minimizes claim assessment and payment
delays; provides the greatest assistance to the insured in resolving the claim;
maximizes cost containment for all carriers sharing the liability; fairly coordinates
benefits among all policies involved; and discourages and identifies duplicate or
fraudulent claim submissions.
2
SCOPE
These Guidelines will apply to all contracts that provide travel health insurance
coverage. Contract wording should indicate that coverage will be coordinated with other
policies according to these Guidelines.
These Guidelines apply to expenses resulting from emergency or elective health care
provided outside Canada or outside the province of residence in excess of the provincial
health plan coverages. These benefits are generally referred to as travel health
insurance
and
can
include
coverage
for
the
following
expenses:
medical/surgical procedures
other physicians' services
confinement and hospital charges
repatriation costs including air ambulance and medical attendants
prescription drugs, para-medical services, etc.
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Retired employees may have extended health coverage through former employers
based on a lifetime maximum for all benefits, including both in-country and
out-of-country extended health coverage.
In order to avoid eroding those lifetime benefits, these guidelines make a provision not
to coordinate with such coverages, if the lifetime maximum is $50,000 or less. In these
cases, a retiree may use alternate coverage purchased through individual or group
travel health insurance products to cover out-of-country expenses. If the individual has
used up alternate coverage sources, the group retiree coverage will be responsible for
any remaining expenses covered under its contract.
If the lifetime maximum for all in-country and out-of-country benefits is greater than
$50,000, full coordination will take place above this amount as outlined in these
Guidelines.
4
The carrier that is first contacted for the purposes of claimant contact, or to whom the
claim is initially submitted by the insured, is considered to be the First Carrier for the
purposes of these Guidelines.
In these Guidelines, plan is defined as group insurance or any other arrangement of coverage
for individuals in a group, whether on an insured or an uninsured basis, including any
prepayment coverage or capitation plan, as long as the group is not formed solely for the
purpose of insurance. This definition of plan does not include school insurance or individual
travel insurance.
For the purposes of coordinating Out-of-Country/Province Health Care Expenses, that definition is
interpreted as including any plan covering extended health benefits as a whole (not travel health
coverage only), that is offered to employees/retirees as a group and is sponsored by an
employer/union/recognized professional association or by a multi-employer association.
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Any other carrier that shares a liability for the claim is defined as an Other Carrier. If
there are more than two policies, there can be two or more Other Carriers.
An insurer cannot systematically or otherwise deflect calls by referring them to another
carrier to avoid becoming the First Carrier. If a carrier feels that its claim assistance
services are not adequate, this matter should be negotiated with the Other Carrier.
6
The First Carrier will take the initiative in the case management and claims
assessment and will pay the claim first, according to the terms; and conditions of its
contract, and reserving all rights to recovery from the Other Carrier(s) and from
provincial health plans. (The First Carrier is never expected to pay more than the
liability under its contract). Wherever possible, the rights to recovery should be made
transparent to the claimant so the individual is aware that the insurance carriers will
coordinate payment of the claim.
Case management includes, but is not limited to: taking the initiative to involve an
assistance group or service provider, choosing a preferred provider organization,
monitoring to ensure appropriate medical care and/or repatriation.
7
The First Carrier must establish whether an Other Carrier exists as quickly as
possible, and must notify each identified carrier. Notification for all in-patient
hospitalizations must occur immediately. For all other claims, notification shall be as
soon as possible.
Prompt notification to all Other Carriers involved in the claim is critical to the effective
coordination of coverages. The initial notification will be a phone call to the Other
Carrier(s) followed by written notification sent within 48 hours.
The initial notification will include all relevant available information2, including for
example (but not limited to):
Name of Individual
Age
Individual or Group Policy Number
Social Insurance Number or Certificate Number
Detailed Diagnosis
Date of Hospital Admission
Name and Location of Hospital
Medical Treatments Provided to Date
Costs Incurred to Date
Departure Date
Government Health Insurance Plan (GHIP) Number
It is important to note that notification by the claimant to the First Carrier is deemed
notification to all Other Carriers that are known and identified at the time and will
serve as notification to those carriers.
Personal information held by one carrier cannot be communicated to another carrier without the consent of the
person concerned. The First Carrier should seek such consent on its claim form or other initial contact.
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CONSULTATIONS/SECOND OPINIONS
In assessing significant or difficult claims, or if the First Carrier does not have
adequate preferred provider or travel assistance arrangements, the First Carrier may
contact the Other Carrier sharing in the claim liability to request assistance, to discuss
the claim or, to ask for a second opinion.
9
Upon receipt of notification, the Other Carrier(s) may offer to provide consultation on
case management to the First Carrier and may provide cost containment options.
Consultation may include but not be limited to the involvement of an assistance group
or service provider, the choice of a preferred provider organization, monitoring to
ensure appropriate medical care and/or repatriation.
Ultimate decisions for the case management remain the responsibility of the First
Carrier.
10
An Other Carrier may take on the responsibility of First Carrier if there is mutual
agreement between the carriers to do so. This would be particularly appropriate if the
First Carrier recognizes that its liability for the claim is limited (for example, if the First
Carrier's liability will be $10,000 and the claim is expected to be $50,000 or more).
11
If the First Carrier has no liability for the claim (for example, if a pre-existing
condition has been clearly established), the First Carrier's responsibility ceases once it
determines it has no liability for the claim and has informed the insured. When this
occurs, the First Carrier will instruct the insured to contact the Other Carrier, if any,
to pursue the claim. To speed up the adjudication process, the First Carrier will still
provide notification to any Other Carrier known at that time, as outlined above.
12
RECOVERY
The process of recovery will take place after the First Carrier has made its assessment
and paid the claim in accordance with its contractual liability. [Recovery between
carriers is net of provincial government health insurance plans (GHIP)
reimbursements.] Copies of the claim documents will then be sent to each of the Other
Carriers involved.
Each carrier receiving the claim documents will assess the claim independently based
on the terms of its own contract, and will identify in a detailed fashion what its payment
would have been if that was the only coverage for this claim. This information will then
be sent back to the First Carrier.
Once all of these responses have been received by the First Carrier, it will determine
the Other Carriers' portion of liability for the claim and it will have the right to recover
from the Other Carrier(s) by using the following rules:
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(1)
(2)
Each Carrier will reimburse the First Carrier for its share of the payment already
made, and will pay the providers or the insured directly for any remaining expenses for
which it has liability. Refer to examples in Appendix B.
Payments and reimbursements will be made as soon as possible.
If the First Carrier has identified the involvement of only one Other Carrier, the
Other Carrier will be informed of this so it can complete the calculations and send its
payment directly to the First Carrier, reducing the need for further correspondence
between the carriers.
13
ADJUSTMENTS
The First Carrier will indicate to the Other Carrier(s) where the original documents
are retained.
15
DISPUTE RESOLUTIONS
The parties may agree that binding arbitration by an independent review committee,
mutually agreed upon by the parties involved, will be used to settle any disputes.
In addition to the actual health care expenses incurred, the following allocated expenses paid during the claim
adjudication process can also be coordinated:
Fees charged by a preferred provider organization (PPO), usually as a percentage of savings, to obtain a
reduction in charges by hospitals, physicians, etc.
Medical reports obtained from hospitals and doctors.
Repatriation as a cost saving measure.
Other appropriate expenses incurred for the purposes of significant cost saving such as outside investigation
expenses, utilization reviews or audit fees, legal fees, etc. should he pre-negotiated between carriers.
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APPENDIX A
COORDINATION OF BENEFIT SAMPLES DENTAL AND HEALTH
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DENTAL
(5 Samples)
DENTAL Sample #1
Expenses eligible under both plans:
Carrier A payment
Plan based on current fee guide.
Date of
Service
1.2.89
1.2.89
1.2.89
1.2.89
Procedure
Code
23222
23221
23221
23222
TOTAL
*
Submitted
Eligible
87.00
46.00
40.00
70.00
79.99*
46.00
40.00
70.00
$243.00
$235.99
Payable at
80%
80%
80%
80%
Payment
63.99
36.80
32.00
56.00
$188.79
Carrier B payment
Plan based on current fee guide. We would not consider $7.01 as eligible because it is
over the fee guide. However, we would consider the 20% balance on all eligible
expenses.
16.00
9.20
8.00
14.00
$47.20
Since we would have paid $188.79 if we had been the only carrier (assuming 80%
reimbursement), we would pay $47.20 ($235.99 - $188.79).
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DENTAL Sample #2
One of the plans has a contract based on an older fee guide.
Carrier A payment
Plan based on 1989 fee guide.
Date of
Service
1.2.90
1.2.90
Procedure
Code
01103
01242
TOTAL
*
Submitted
73.98
16.53
$90.51
Eligible
69.96*
15.63*
Payable at
100%
100%
$85.59
Payment
69.96
15.63
$85.59
Carrier B payment
Plan based on current fee guide.
Date of
Service
1.2.90
1.2.90
Procedure
Code
01103
01242
TOTAL
Submitted
Eligible
Payable at
73.98
16.53
73.98
16.53
80%
80%
$90.51
$90.51
Payment
59.18
12.50
$71.68
Since the dentist is not charging more than the current appropriate provincial fee guide,
we will pay $4.92 ($90.51 - $85.59).
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DENTAL Sample #3
Both plans cover general practitioners only but work is performed by specialist
(endodontist):
Carrier A payment
Plan based on current GP fee guide.
1.2.90
1.3.90
Procedure
Code
Submitted
Eligible
01205
33101
88.77
295.00
73.98*
246.00*
TOTAL
*
$383.77
Payable at
100%
100%
$320.58
Payment
73.98
246.00
$320.58
Carrier B payment
Plan based on current GP fee guide.
Date of
Service
1.2.90
1.3.90
Procedure
Code
01205
33101
Submitted
Eligible
Payable at
Payment
88.77
295.00
73.98*
246.60
80%
80%
59.18
197.28
$383.77
*
$320.58
$256.46
$63.19 declined as being over the 1990 GP guide. Since the dentist has not
overcharged according to the current appropriate (endodontist) fee guide, we will
pay $63.19 ($383.77 - $320.58).
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DENTAL Sample #4
Expenses eligible under other carrier but not under our plan:
Carrier A payment
Plan based on current fee guide.
Date of
Service
1.2.89
1.2.89
1.2.89
1.2.89
Procedure
Code
23222
23221
23221
23222
TOTAL
Submitted
Eligible
87.00
46.00
40.00
70.00
$243.00
Payable at
79.99*
46.00
40.00
70.00
$235.99
80%
80%
80%
80%
Payment
63.99
36.80
32.00
56.00
$188.79
Carrier B payment
Plan based on current fee guide.
Procedure code 23222 is not eligible under our plan.
The balance of 23222 should not be considered under our plan.
The balance of 23221 can be considered.
9.20
8.00
$17.20
Since we would have paid $68.80 for these two services if we had been the only carrier
(assuming 80% reimbursement), we would pay $17.20.
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DENTAL Sample #5
Expenses which are not eligible under either plan:
Carrier A payment
Date of
Service
1.2.89
1.2.89
1.2.89
1.2.89
Procedure
Code
23222
23221
23221
23222
TOTAL
*
Submitted
Eligible
87.00
46.00
40.00
70.00
0.00*
46.00
40.00
0.00*
$243.00
$86.00
Payable at
80%
80%
Payment
0.00
36.80
32.00
0.00
$68.80
Carrier B payment
We would not consider either 23222 amounts since they are not eligible under our plan.
We would consider the balance of:
9.20
8.00
$17.20
Since we would have paid $68.80 if we had been the only carrier, we would pay $17.20.
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DRUGS
(6 Samples)
DRUGS Sample #1
Carrier A payment
50.00
80%
$40.00
Carrier B payment
50.00
80%
$40.00
submitted
co-insurance
paid
submitted
co-insurance
we would have paid
DRUGS Sample #2
Carrier A payment
Drugs submitted are $2.00; $5.00; $10.00
17.00
80%
$13.60
submitted
co-insurance
paid
Carrier B payment
The $5.00 drug is ineligible with us, so we pay 20% of the eligible drugs only.
17.00
12.00
20%
submitted
eligible
(out-of-pocket)
$2.40
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DRUGS Sample #3
Carrier A payment
50.00
-25.00
80%
submitted
deductible
$20.00
paid
50.00
-50.00
deductible
Out-of-pocket - $30.00.
Carrier B payment
We would have considered:
$0.00
The out-of-pocket is $30.00. (We only pay up to what we would have paid, if we were
the first carrier.)
DRUGS Sample #4
Carrier A
50.00
-50.00
$ 0.00
Carrier B
deductible
50.00
-50.00
deductible
$ 0.00
The deductibles are satisfied under both plans. The out-of-pocket expense is $50.00.
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DRUGS Sample #5
Drugs submitted:
2.00
5.00
10.00
10.00
Carrier A Payment
Carrier B payment
27.00
-20.00
deductible
$ 7.00
paid
27.00
- 5.00
ineligible
$22.00
-10.00
80%
deductible
$ 9.60
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DRUGS Sample #6
Drugs submitted:
2.00
5.00
10.00
10.00
$27.00
Carrier A payment
27.00
- 7.00
deductible
$20.00
80%
Out-of-pocket $11.00
Carrier B payment
$16.00
27.00
- 5.00
paid
ineligible
$22.00
80%
$17.60
We do not know which expenses were applied towards the deductible by the first
carrier. We would have paid more than the out-of-pocket amount, so we pay all of the
out-of-pocket $11.00.
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VISION
(2 Samples)
VISION Sample #1
Glasses $210.00
Carrier A pays:
150.00
-25.00
deductible
$125.00
80%
Out-of-pocket - $110.00.
Carrier B pays:
B pays
$100.00
150.00 maximum
100%
$110.00
VISION Sample #2
Glasses $240.00
Carrier A pays:
Out-of-pocket - $90.00.
Carrier B pays:
150.00 maximum
100%
$150.00
100.00
-25.00 deductible
$75.00
80%
$60.00
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HOSPITAL
(3 Samples)
HOSPITAL Sample #1
($50.00 SP, $40.00 PR, $90.00 per day private)
Carrier A:
Carrier B:
HOSPITAL Sample #2
(SP $50.00, Private $40.00)
Carrier A:
Carrier B:
HOSPITAL Sample #3
($40.00 SP; Private $30.00)
Carrier A:
Carrier B:
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SUPPLEMENTARY
(1 Sample)
SUPPLEMENTARY Sample #1
Massage visits - 10 visits at $25.00 each = $250.00
Carrier A pays:
250.00
submitted
200.00
-50.00
maximum eligible
deductible
$150.00
80%
$120.00
paid
Carrier B pays:
Our maximum is $250.00 at 80%.
We pay $130.00 in full.
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Procedure/
Service
G4 Coordination of Benefits
Amount
Charged
Payment by
1st Carrier
Balance
2nd Carrier
Could Have
Paid
Amount
Covered
Out-ofPocket
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APPENDIX B
COORDINATION OF BENEFIT SAMPLES: OUT-OF-COUNTRY/
PROVINCIAL HEALTH CARE EXPENSES
Example 1 .......................................................................................................24
Example 2 .......................................................................................................25
Example 3 .......................................................................................................26
Example 4 .......................................................................................................27
Example 5 .......................................................................................................28
Example 6 .......................................................................................................29
Example 7 .......................................................................................................30
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Example 1
ITEM
Hospital Ward
(25 days)
Semi-private excess
Physician
Private Duty Nursing
Repatriation
Accompanying Family Member
TOTAL
Liability if
Carrier 1
alone
($)
Liability if
Carrier 2
alone
($)
Common
Core
($)
50,000
50,000
49,000
49,000
2,000
n/a
2,000
20,000
20,000
20,000
20,000
5,000
n/a
5,000
5,000
5,000
15,000
5,000
15,000
5,000
10,000
15,000
1,000
n/a
1,000
1,000
1,000
93,000
75,000
92,000
Total bill
after GHIP
($)
Carrier 1
Exclusive
($)
Carrier 2
Exclusive
($)
1,000
Total
($)
50,000
2,000
2,000
20,000
74,000
1,000
18,000
93,000
37,000
1,000
n/a
38,000
37,000
n/a
18,000
55,000
n/a
n/a
n/a
n/a
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Example 2
ITEM
Total Bill
after
GHIP
($)
Carrier 1
Liability
if alone
($)
Carrier 2
Liability
if alone
($)
Carrier 3
Liability
if alone
($)
Common
Core
($)
Hospital
(140 days)
700,000
280,000
560,000
700,000
280,000
Physician
150,000
150,000
120,000
150,000
120,000
50,000
5,000
40,000
50,000
5,000
35,000
10,000
50,000
2,000
1,600
2,000
1,600
400
2,000
902,000
435,000
721,600
902,000
405,000
30,000
316,600
150,400
902,000
135,000
15,000
n/a
n/a
n/a
n/a
150,000
135,000
n/a
158,300
n/a
n/a
n/a
293,300
135,000
15,000
158,300
n/a
n/a
150,400
458,700
n/a
n/a
n/a
n/a
n/a
n/a
Repatriation
-ambulance
MRI
TOTAL
Note:
n/a
1&2
Only
Jointly
($)
1&3
Only
Jointly
($)
2&3
Only
Jointly
($)
Carrier 1
Exclusive
($)
Carrier 2
Exclusive
($)
280,000
Carrier 3
Exclusive
($)
Total
($)
140,000
700,000
30,000
150,000
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Common Core
Hospital
80,000
80,000
80,000
80,000
Physician
20,000
20,000
20,000
20,000
TOTAL
100,000
100,000
100,000
100,000
Share of Carrier 1
100,000
Share of Carrier 2
n/a
Share of Insured
n/a
Note:
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Carrier 1
Liability
if alone
($)
Carrier 2
Liability
if alone
($)
Carrier 3
Liability
if alone
($)
Group Unit
Carrier 2 &
3 if alone 1
($)
Common
Core 2
($)
Hospital
80,000
80,000
80,000
72,000
80,000
80,000
80,000
Physician
20,000
20,000
20,000
18,000
20,000
20,000
20,000
100,000
100,000
100,000
90,000
100,000
100,000
ITEM
TOTAL
100,000
Carrier 1
Exclusive
($)
Carrier 2
Exclusive
($)
Carrier 3
Exclusive
($)
Total
($)
50,000
n/a
n/a
n/a
50,000
50,000
n/a
n/a
n/a
50,000
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Note:
1
2
3
Carrier
Carrier
Carrier
Carrier
1
2
2
3
is an individual policy
and 3 are group policies offered through employment
is the insureds plan
is the insureds spouses plan and has 90% coverage
G4 Coordination of Benefits
27 of 30
Example 5: High Deductible Individual Policy and Limited Lifetime Retiree Group Policy
Total bill
after GHIP
($)
ITEM
Carrier 1
Liability if
alone
($)
Carrier 2
Liability if
alone
($)
Common
Core 1
($)
Carrier 1
Exclusive
($)
Carrier 2
Exclusive
($)
Total
($)
Hospital
80,000
75,000
50,000
50,000
75,000
5,000
80,000
Physician
20,000
20,000
20,000
20,000
100,000
95,000
50,000
50,000
95,000
5,000
100,000
95,000
95,000
n/a
5,000
5,000
n/a
n/a
n/a
TOTAL
n/a
100,000
Note:
1
G4 Coordination of Benefits
28 of 30
Carrier 1
Liability if
alone
($)
Carrier 2
Liability if
alone
($)
110,000
105,000
100,000
100,000
5,000
105,000
20,000
20,000
20,000
20,000
130,000
125,000
100,000
100,000
25,000
125,000
50,000
25,000
75,000
50,000
50,000
n/a
n/a
n/a
ITEM
Hospital
Physician
TOTAL
Common
Core
($)
Carrier 1
Exclusive
($)
Carrier 2
Exclusive
($)
Total
($)
5,000
130,000
Note:
G4 Coordination of Benefits
29 of 30
Carrier 1
Liability if
alone
($)
Carrier 2
Liability if
alone
($)
110,000
105,000
110,000
105,000
5,000
110,000
20,000
20,000
20,000
20,000
130,000
125,000
110,000
105,000
20,000
5,000
130,000
52,500
20,000
72,500
52,500
5,000
57,500
n/a
n/a
n/a
ITEM
Hospital
Physician
TOTAL
Common
Core
($)
Carrier 1
Exclusive
($)
Carrier 2
Exclusive
($)
Total
($)
130,000
Note:
G4 Coordination of Benefits
30 of 30