Insurance · Policy Provisions

In health insurance, what is 'coordination of benefits' (COB)?

Correct answer

A provision used when a person is covered by more than one health plan, determining which plan pays first (primary) and which pays second (secondary), to prevent duplicate payment exceeding the actual cost

  1. A Choosing a doctor
  2. B A provision used when a person is covered by more than one health plan, determining which plan pays first (primary) and which pays second (secondary), to prevent duplicate payment exceeding the actual cost
  3. C A type of deductible
  4. D A government subsidy

Why this is the answer

COORDINATION OF BENEFITS (COB): A provision/process used when a person is covered by MORE THAN ONE health plan (e.g., their own employer plan and a spouse's plan). PURPOSE: Determines the ORDER of payment — which plan is PRIMARY (pays first) and which is SECONDARY (pays second) — and prevents the total reimbursement from EXCEEDING the actual cost (no profiting from duplicate coverage); HOW IT WORKS: The primary plan pays as if it were the only coverage; the secondary plan may pay some or all of the remaining eligible costs (up to its limits), but combined payment won't exceed 100% of the allowed charges; COB RULES: Determine primacy (e.g., one's own employer plan is usually primary over a spouse's; the 'birthday rule' for children covered by both parents); PREVENTS: Overpayment and duplicate benefits; ensures orderly payment; COB is an important health insurance policy provision on the exam — it manages multiple coverage to determine payment order and prevent paying more than the actual cost.
Source: Health Insurance — Policy Provisions, Coordination of Benefits

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