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Asked: Apr 27, 2010

Where do I find the laws that cover coordination of benefits between plans?

I have a Small Business related question. My wife works for the U.S. Post Office with Federal Blue Cross for both of us. I am totally disabled and have been since 1990. I have Medicare as well as the group health from my work Blue Cross of MA for me and my wife. We have been told that my wife's coverage pays for us both first. Then I have Medicare which pays net for me, and then we have my coverage from my work which pays third for me and second for my wife. We agree with this, but this year my company changed insurance companies and when they pay, they want to only pay part of the claims and also charge us another co-pay. Everything I have read they should pick up the balance due at 100 percent because they are paying the least. Where do I find the laws that cover coordination of benefits and what the last company should pay? Is there anything in writing that is law and we do not have to always wonder who is right.

Categories: In Massachusetts

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It’s challenging enough for most people to manage and understand one insurance policy, so we sympathize with your situation. However, with all of the uninsured people in this country, don’t you feel a bit guilty having three health insurance policies (joking)? Coordination of benefit laws are at the state level. In Iowa, they are part of the Insurance Division Code 191, Chapter 38. Here is a direct link to the law: www.legis.state.ia.us/ACO/I..
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By the time you read through and understand this law, you might be in need of coordinating benefits for the treatment of a nervous breakdown. — June 30, 2009 @ 2:19 pm

Answered: Apr 29, 2010


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nim

Coordination of benefits is handled as part of state insurance regulation. Model coordination of benefits rules are put out by the National Association of Insurance Commissioners (NAIC). The NAIC rules are model rules, which states are free to adopt or ignore, but most states have rules similar to the NAIC rules, and most insurers follow rules that are similar. Massachusetts generally follows NAIC rules, with some exceptions that are probably not relevant, but the first place to look for guidance is in the Blue Cross Evidence of Coverage for your plan, which should cover basics of how Blue Cross coordinates benefits. If you feel that Blue Cross is not following its own rules, call their member service line and complain about how your claims were handled. If you are not satisfied with the resolution of the complaint, you should be able to appeal the company's decision. If nothing else, this will give you a clearer answer about how the claims were processed and why the company took the action it took. A link to Massachusetts COB regulations is below.

Source: http://www.mass.gov/Eoca/do...

Answered: Mar 16, 2011

 

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