Two plans at once and COBRA

This page is short on purpose. The rules for which plan pays first, and the rules for continuation coverage after a job change, are not among the facts this site has been able to confirm from federal sources. So it says what it can stand behind, and sends you to the people who can answer the rest.

What this means

If you have two health plans, one is meant to pay first and the other to pay what is left. The rules that decide the order are called coordination of benefits. A common trap is that each plan says the other should pay first, and your claim is denied by both while the provider’s bill grows. A denial letter may describe this as another insurer being primary. See Another insurer is primary.

We could confirm only a few of the ordering rules. Ask each plan.

• Medicare and Medigap. Medicare pays its share first, and then your Medicare Supplement (Medigap) policy pays its share. A Medigap policy cannot be used to pay Medicare Advantage copayments, deductibles or premiums.
• Medicare and TRICARE. When Medicare denies a service that both programs cover, the appeal goes to Medicare first. TRICARE appeal rights apply only when TRICARE, and not Medicare, would pay.
• Indian Health Service. Purchased/Referred Care is the payer of last resort, after Medicare, Medicaid, private insurance and other resources.

For two private plans, such as a plan through your job and a plan through a spouse’s job, this site does not state which plan is first.

COBRA

Continuation coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) is a way for some people to stay on a job-based plan. We could not confirm who is eligible, how long it lasts, the deadline to elect it, or what it costs. Do not rely on this site for those.

The plan you continue is the same plan you had. This site has not confirmed whether continuation coverage changes the steps or deadlines for an appeal, so ask the plan administrator in writing, and keep the answer.

What to do

1. Collect both plans’ statements (you). Look at each Explanation of Benefits for the reason and the date.
2. Ask each plan in writing which one pays first for this claim, and why (you). Ask which rule it relies on. Send each plan’s answer to the other plan.
3. Ask the provider’s billing office to resubmit in the right order (your provider). They need both plans’ details.
4. Appeal on time anyway (you). If either plan has issued a denial, its appeal deadline keeps running while the two plans decide who goes first. Use the date on the notice. See the employer plan appeal path.
5. For COBRA questions, ask the plan administrator and the Department of Labor (you). The administrator is named in your plan documents. The Employee Benefits Security Administration (EBSA), part of the Department of Labor, publishes guides on continuation coverage and offers an advisor service. Its help line is 1-866-444-3272.
6. Keep a log (you). Keep a call log shows how.

Check the date on your notice, which controls.

The rule

When Medicare denies a service that both Medicare and TRICARE cover, the appeal goes to Medicare first. TRICARE appeal rights apply only when the service is payable by TRICARE and not by Medicare. (Title 32 of the Code of Federal Regulations (CFR), section 199.10(a)(1)(ii)(B))

Watch for

• Refund demands. Community discussions of two-insurer disputes mention refund-demand letters. If you get one, read the deadline in it and ask the plan to explain in writing.
• A coverage gap. If a denial says your coverage was not active, see Coverage not active.
• Advice from a billing office. A provider’s office may know the usual order for your plans, but the answer you can rely on is the plan’s own, in writing.

What next

• Employer plans: the complete appeal path covers the appeal once you know which plan denied the claim.
• Get help from the Department of Labor explains what EBSA can do for you.
• Where to get free help lists people who can look at your two plans with you.