Penn State Hershey Medical Center Benefits Administration wants to make sure that you understand how your benefit coverage works when you have multiple insurances.
A few simple guidelines to assure maximum benefit are:
| Scenario | Explanation |
| If you have other insurance, then … | Highmark sends you a Coordination of Benefits (COB) questionnaire to determine which plan is primary |
| If services are rendered to you, and you are the employee under the plan, then… | Your plan through your employer is the primary plan for you. |
| If services are rendered to your spouse, who has a policy through another insurance carrier, then… | Your spouse's own policy is the primary plan for your spouse. |
| If services are rendered to a dependent, who is covered by both parents' policies and both policies have the birthday rule, then… | Coverage for the parent whose birthday falls earliest in the year (month and day) is the primary plan. |
| If services are rendered to a dependent who is covered by both parents' policies and both policies have the birthday rule and both parents are born on the same month and day, then… | The primary plan is the policy that covered the patient for the longest period of time. |
| If one insurance company follows the birthday rule and other follows the gender rule, then… | The policy with the gender rule dictates the father's coverage to be the primary plan. |
| If parents are divorced and there is a court order stating which parent is primary, then… | The policy of the parent listed on the court order is the primary plan. |
| If parents are divorced and no court order, then… | The parent with custody is the primary plan. |
| If parents are divorced and parent with custody remarried, then… | The plan of the stepparent with custody is primary over the natural parent without custody. |
| If parents have joint custody, then… | The primary plan is determined by birthday or gender rule. |
| f the dependent/child is an overage student and custody is no longer an issue, then… | The parent the child resides with is the primary plan. |
There are different ways to handle coordination of benefits. Highmark is currently coordinating benefits in accordance with a national standard established by the National Association of Insurance Commissioners (NAIC). Highmark follows the NAIC model regulations with regard to what is eligible for reimbursement under the secondary carrier. When the Highmark plan is secondary, Highmark determines what they would have paid as the primary plan. If the other plan already paid that amount or more, Highmark does not pay anything additional. If the other plan paid less than what Highmark’s allowance would have been, Highmark would pay the difference between the two (up to a "total" of what Highmark would have paid as the primary plan).
For example:
Your spouse paid a $25 copay for an office visit using your spouse’s primary insurance. Your spouse's primary insurance paid $45 to the participating provider for a total outlay of $70.
As secondary insurance, Highmark's allowance for this office visit was $62. Highmark would apply your $20 copay and would have paid $42 to the participating provider for a total outlay of $62.
Since the primary plan already paid $45 and your spouse paid a $25 copay for a total outlay of $70; Highmark would not pay anything further on this claim as it exceeds Highmark's $62 allowance.
If you are a Highmark BlueShield member and you cover dependents under your plan, you should have received a Coordination of Benefits (COB) Questionnaire at your home address in the month of March. If you cover dependents and never received a COB questionnaire, contact Highmark Customer Service at (800) 914-4808 to complete.