Coordination of benefits is confusing. Can you provide some examples for dual coverage with medical plans so I can get a better understanding of how benefits will be coordinated?
In most cases, once the deductibles are satisfied, members will not have any further out-of-pocket costs, unless limitations or maximums are required. If members seek services from out-of-network providers, they will be responsible for any charges in excess of the ODS maximum plan allowance (MPA). If a member has secondary coverage through a non-ODS plan, he or she should check with that plan’s insurance carrier on how it handles coordination of benefits. Please see below for sample scenarios. Medical coordination of benefit examples: All examples assume use of in-network providers. Example #1 A claim for knee replacement comes in for a member on Plan 3 primary and Plan 6 secondary. Assuming the billed amount and allowed amount is $5,000, the claim would be processed as follows. The knee replacement is in the additional cost tier with a $500 copay. This comes out first, then the Plan 3 $200 annual deductible is applied. Once the deductible is met, ODS pays 90 percent of the remainder a
