. Group Benefits Plans - General EBN Archives: Show me articles about Select a Category Wellness Report Administrative Update Group Benefits Bulletins Front Runner The Script e Benefit News RAMQ Technology group benefit plans - general plan administration drug care dental care life insurance health care disability management health and wellness programs Manulife Financial news Industry standards and guidelines general legislative changes fee schedules taxation rules Coordination of Benefits   Deciphering COB for divorced, separated, re-married, and common-law plan members At the beginning of 2009, revised guidelines from the Canadian Life and Health Insurance Association came into effect concerning coordination of benefits (COB) procedures for plan members who can submit a claim to more than one group benefits plan. The new guidelines do not introduce any significant changes, but they do clarify the process in unique situations such as those concerning various family living situations. Maximizing coverage Millions of Canadians have health and dental coverage through their own employee benefits plan, and are also eligible for coverage as a dependant under their spouse's insurance plan. The COB guidelines allow plan members to use the coverage available to them through both plans to recover up to 100 per cent of their expenses by allowing both eligible benefits plans to share the total cost of the expense. COB also saves the benefits plan money by ensuring claims are submitted to the plans in the correct order, regardless of the amount of coverage each plan offers. Order of operation Coordination of benefits will work properly if plan members understand which insurance plan to submit their claims to first. In the case of claims for the plan member, the industry guidelines establish the plan member's group benefits plan as the first payer, the dependant coverage available through his or her spouse's plan as the second payer, and then any Health Care Spending Account coverage as the third payer. If the plan member and his or her spouse both have insurance company drug cards, pharmacists can coordinate claims payments for both plans right at the pharmacy drug counter. Claims for dependent children The birthday rule is used to determine the order that claims are submitted for a dependent child. Claims are submitted first to the benefits plan for the parent whose birthday (month and day) occurs earlier in the calendar year, regardless of age. For example, a 44 year old father born on April 4 would submit the claim to his plan first if his 45 year old wife was born on October 10. Following this, the claim (copies of the receipts and the explanation of benefits from the first insurer) can be submitted to his wife's plan so that any remaining balance can be considered for payment. If both parents share the same birth month and day, the alphabetical order of the parents' first names determines which plan the claim is submitted to first. Concerning parents who are divorced, separated, re-married, or in a common-law relationship There are COB guidelines that determine the order claims for dependent children should be submitted when the parents (including same sex parents) are divorced, separated, re-married, or living in a common law arrangement. In most cases, each benefits plan issues any payments to the plan member, regardless of the custody arrangement*. This means payments could be issued to the parent not incurring the actual expense. Single custody – an arrangement in which one parent has legal custody of the child and the child lives with that parent. Joint custody – any arrangement other than 'single custody'. Single custody Submit claims in the following order: To the plan of the parent with single custody of the child. To the plan of the (new) spouse (if applicable) of the parent with single custody of the child. To the plan of the parent without single custody of the child. To the plan of the (new) spouse (if applicable) of the parent not having custody of the child. Joint custody Submit claims in the following order: To the plan of the parent with joint custody whose birthday (month and day) occurs earlier in the calendar year, regardless of age. The plan of the other parent with joint custody. The plan of the (new) spouse (if applicable) of the parent whose birthday (month and day) occurs earlier in the calendar year. The plan of the (new) spouse (if applicable) of the other parent with joint custody. If both parents with joint custody share the same birth month and day, the alphabetical order of the parents' first names determines which plan the claim is submitted to first. *In the event a parental relationship has broken down and the parent who incurred the dependent child's expenses is unable to recover payment from the parent whose plan is the first payer, the guidelines permit the order of payment to be changed. The plan sponsor of the parent who incurred the charges, as well as the insurance company that provides the plan, must be in agreement with the change. In addition, a plan member can also contact his or her ex-spouse's insurance company to see if special claim submission and/or payment arrangements can be made. These inquiries need to be made before the cost is incurred. Source: Canadian Life and Health Insurance Association