What is coordination of benefits?

What does coordination of benefits mean?

When someone is covered by more than one benefits plan, the plans work together to pay any claims.

How does coordination of benefits work?

There are 3 main scenarios where coordination of benefits comes into effect. In each case, one plan pays first (the primary payor) and one plan pays second (the secondary payor).  

• Scenario 1: You're covered under your employer’s benefits plan and as a dependant under your partner’s plan
• Scenario 2: Your partner is covered under their employer’s benefits plan and as a dependant under your plan
• Scenario 3: Your dependant kid(s) has coverage under both you and your partner’s benefits plans

How do you determine which plan pays first?

Look for your scenario below and then submit your claims in the order shown. Send your claim to the first plan on the list. After your claim has been processed, if there are any unpaid amounts, submit a claim to the next plan on the list. Work your way down the list 1 by 1 as applicable.

I’m married (or living common-law) and we each have a workplace benefits plan

1. Your own benefits plan.
2. Your spouse’s plan. 

Likewise, your spouse’s claims should be submitted to their own plan first.

I’m married (or living common-law) and we’re submitting a claim for our child

1. Plan of the parent whose birthday (month and day) falls earlier in the calendar year (ignore the year of birth and just look at month and day).
2. Other parent’s plan.

I have joint custody of my children. My ex and I are each remarried or living common-law.

1. Plan of parent whose birthday come first in the calendar year (ignore the year of birth and just look at month and day).
2. Plan of the second parent.
3. Plan of the spouse of the parent whose birthday comes first.
4. Plan of the spouse of the second parent.

I have sole custody of my children. My ex and I are each remarried or living common-law.

1. Plan of the parent with sole custody.
2. Plan of the spouse of the parent with sole custody.
3. Plan of the second parent.
4. Plan of the spouse of the second parent.

I’m a full-time university student with coverage through my university and through my job, but am also considered a dependant under my parent’s plan. 

1. Your student or work plan, whichever one you got coverage with first.
2. Your student or work plan, whichever one you got coverage with second.
3. Your parent’s plan. 

Exception: If the student is a Quebec resident, and is submitting a drug claim, submit to the student plan last.

I have 2 jobs and have coverage with both

• Plan of the full-time job.
• Plan of the part-time job. 

Note: If you work the same hours at both jobs or have 2 part-time jobs, submit to the plan of the job where you started working first.

I have a retiree plan and a plan at my new job

• Plan of your new job.
• Retiree plan.

How are coordination of benefits claims reimbursed?

Submit your claim to your benefits plan first, for payment according to your coverage. 

Once you receive an explanation or statement of benefits for that claim, you can submit a claim for the remaining amount to the second plan and it will be paid according to the coverage of that plan. 

The reimbursement under both plans won’t be more than 100% of the original claim amount.