KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST A Nonprofit Corporation Coordination of Benefits Consumer Explanatory Booklet Important Notice This is a summary of only a few of the provisions of your health plan to help you understand coordination of benefits, which can be very complicated. This is not a complete description of all of the coordination rules and procedures, and does not change or replace the language contained in your Evidence of Coverage (EOC), which determines your benefits. It is common for family members to be covered by more than one health care plan. This happens, for example, when a husband and wife both work and choose to have family coverage through both employers. When you are covered by more than one health plan, state law permits issuers to follow a procedure called “coordination of benefits” to determine how much each should pay when you have a claim. The goal is to make sure that the combined payments of all plans do not add up to more than your covered health care expenses. Coordination of benefits (COB) is complicated and covers a wide variety of circumstances. This is only an outline of some of the most common ones. If your situation is not described, read your Evidence of Coverage or contact your state insurance department. Primary or Secondary? You will be asked to identify all the plans that cover members of your family. We need this information to determine whether we are the “primary” or “secondary” benefit payer. The primary plan always pays first when you have a claim. Any plan that does not contain your state’s COB rules will always be primary. If you are covered by more than one health benefit plan, and you do not know which plan is your primary plan, you or your provider should contact any one of the health plans to verify which plan is primary. The health plan you contact is responsible for working with the other plan to determine which is primary and will let you know within 30 calendar days. Caution: All health plans have timely claim filing requirements. If you or your provider fail to submit your claim to a secondary plan within that plan’s claim filing time limit, the plan can deny the claim. If you experience delays in the processing of your claim by the primary health plan, you or your provider will need to submit your claim to the secondary health plan within its claim filing time limit to prevent a denial of the claim. To avoid delays in claims processing, if you are covered by more than one plan, you should promptly report to your providers and plans any changes in your coverage. When This Plan is Primary If you or a family member is covered under another plan in addition to this one, we will be primary when:  Your Own Expenses. The claim is for your own health care expenses, unless you are covered by Medicare and both you and your spouse are retired.  Your Spouse’s Expenses. The claim is for your spouse, who is covered by Medicare, and you are not both retired. CWCOB0124 1