Coordination of Benefits

What is Coordination of Benefits (COBS)?

Canadians can have more than one health insurance plan or provider, depending on their needs. There are ways for you to maximize the coverage of your medical services, including prescription drugs and dental services. You can achieve managing two or more insurance policies via Coordination of Benefits (COBS).

This article will be reviewing the Coordination of Benefits in Canada and what it entails.

Coordination of Benefits

Coordination of benefits is a standard provision in health plans and benefit carriers in Canada. It allows individuals, couples, and families with more than one health plan to receive full coverage for medical services.

That is, as a member of a health plan or benefits carrier, you can get up to the maximum amount for eligible prescription drugs, dental and health claims. In addition, you and your spouse or common-law partners can benefit from each other’s plans.

Although, as an individual, you can also coordinate the benefits of more than one private health plan. However, it is only applicable when the combined reimbursement from all the plans cannot be more than the incurred expenses.

Features of Coordination of Benefits

The Coordination of Benefits is systematically designed to fit every lifestyle. Hence, there are different features regardless of your status. Below is how Coordination of Benefits facilitates your plans:

For an individual

As an individual with multiple plans, your coverage determines the position of the plans. Also, your health claims will be divided proportionately between the plans.

For married couples

Each spouse’s plan is considered the primary plan. And any outstanding claims will be sent to the other spouse’s plan and regarded as the secondary plan.

Also, for direct bill plans like dental plans and prescription drugs, the provider will submit the claims to the appropriate benefit carriers on their behalf.

For instance, Susan and David are a couple. When they submit their claims to their primary health plan or benefit carriers, they will each receive an Explanation of Benefits. Afterward, Susan’s outstanding claims will be sent to David’s benefits carrier, and David’s outstanding claims will be sent to Susan’s plan or benefits carrier.

For families with dependent children

The parent whose birthday falls earlier in the calendar year will be the primary plan holder for the children. For instance, if you have your birthday earlier than your spouse, you will be the holder of the primary plan for your children. Conversely, if it’s your spouse, they will be the holder of the primary plan.

If you and your spouse have the same birth month regardless of birth year, whoever has the earlier birthday gets to be the primary plan holder. Also, if you share the same birthday, the spouse whose first letter of their official name is closest to the beginning of the alphabet (the letter ‘A’) will be the primary plan holder.

Based on the example above, if Susan and David have the same birthday, David will be considered the primary plan holder for their children.

For divorced or separated parents

The coordination of benefits for dependent children is similar to that of the married parents, except one of the parents wants sole custody. If you want sole custody for your dependent child or children as a divorced or separated parent, you will reach out to your carrier for details on the process.

How Coordination of Benefits Works

Coordination of benefits varies with each health plan or benefits carrier. Hence, you have to consult your health plan contract or benefits carrier for information on how to go about it.

There is a general framework for the coordination of benefits. The framework requires that you submit claims to your primary benefit carrier or health plan for review.

Also, you have to submit all payments according to your coverage and benefits. Afterwards, you will then receive an Explanation of Benefits or a statement. Once you receive this, you can proceed to submit a claim for the eligible unpaid amount to your second plan or your spouse’s or common-law partner’s plan.

In coordination of benefits, there’s the preliminary plan and the secondary plan. However, if you have more than one health plan as an individual, a couple or family, it is up to you to determine which plan is primary and secondary. In addition, the preliminary plan always pays first while the secondary plan settles outstanding payments.

Coordination of Benefits for Public Service Health Care Plan (PSHCP)

Coordination of benefits between two PSHCPs is allowed for members of the PSHCP. To be eligible to coordinate your benefits, you will need to have family coverage and complete the positive enrolment to include your spouse or common-law partner. All you have to do is complete the coordination of the benefits section when submitting a PSHCP claim.

Conclusion

Coordination of benefits is a great way to get maximum coverage for health and medical services in Canada. It is for individuals, couples, and families with more than one health plan or benefits carrier. Also, members of the Public Service Health Care Plan can leverage coordinated benefits if they have more than one provider.

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