Source
r/HealthInsurance•
UserNotFound-Error

COB non-duplication

Plan Benefits

So a buddy and I have been going back and forth on a question about COB non-duplication . We came up with an example but then realized we both came up with different outcomes and couldn’t decide what the correct one was.

Example:

A subscriber has 2 insurance policies and they cover as follows

Policy A: Co-ins 70/30 Deductible $200

Policy B: Co-ins 80/20 No deductible

On a claim that has an allowed amount of $300, policy A would pay as primary the following way

Subs pays deductible: $200 Policy A pays $70 Subs pays $30

If Policy B were primary it would pay the following way, same allowed amount of $300

Policy B pays $240 Subs pays $60

Now putting it together with both plans

If policy A is primary and Policy B is secondary, then

Policy A would pay $70 Since the subscriber is left with a deductible ($200) and co-insurance ($30) I think Policy A would push $230 to Policy B, at which point policy B would only pay the difference of the allowed amount ($240) and the total amount left over that Policy A did not pay ($230) so I say Policy B would only pay $10

My friend says that since the Subs needs to pay the deductible of $200 for Policy A then only the $30 gets pushed to Policy B, at which point Policy B would pay $210

Can anyone help me out and figuring what is the correct calculation

Thank you

Posted Jun 15, 2022, 4:22 AM UTC

25
bigredmer•

You are both incorrect. Policy B would ensure that its benefits were applied, because its benefits are better. In this case, it would normally pay 80% of allowed, which is $240. That leaves $60 for member to pay. Policy A already paid $70, leaving $170 for Policy B to pay.

If policy B was primary, it would pay its $240, leaving $60. With Policy A as secondary, the $200 deductible would be satisfied, but it wouldn't make any payments because of the non dup.

3
UserNotFound-ErrorOP•

Excellent thank you so much for the clarification

2
LivingGhost371•

There was a COB type that worked more or less like the way you described it, but it's not "Non Dupe" and isn't very common any more

Another way to think of it is both policies initially process the claim agnostic of what the other policy- the secondary policy doesn't care what the allowed amount or the cost sharing is the primary. The secondary subtracts what the primary paid from what it would have paid to the provider in the absence of COB and pays the provider the balance, if any, and the subscriber is left responsible for the lesser of the two cost sharing amounts, in this case it's the secondary, because $60 is less than $230.

2
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1
UserNotFound-ErrorOP•

Yeah there’s a few out there, the most common one I see at my job is the non-duplication. The other one that I also see more frequently is the Standard COB.

1