Order of Benefits? Plan member is the insured under 2 health policies

[Guest Damien]

Plan member is the insured, with full coverage, under both these policies at the same time:

Self-Funded Policy

hired 11-07-98, with full coverage effective immediately.

Fully Insured Policy

hired 10-25-98, with a 60 day waiting period for full coverage to become effective

I always heard in such a case, the policy in effect longer is prime, but this case raises the question of when to start counting: hire date or effective date of coverage? Also, does the fact that one Plan is fully insured vs. the other being self-funded make a difference?

To add a possible further twist, I believe the fully- insured plan is for a non-federal government entity, and the self-funded plan we administer is also a non-federal government entity, although as far as I know they do not opt out of any requirements on that basis.

Any opinions out there?

[KIP KRAUS]

In my opinion, you need only check the COB provisions of both plans. If both plans consider the plan in effect the longest as primary (most plans do use this method) then the plan in effect the longest would be primary. Hire date shouldn't have anything to do with how long coverage is in effect. The effective date of coverage should rule.

Self-insured or insured shouldn't make any difference in how COB is determined. However, the self-insured plan could have some twist to its COB provision that may be different than the fully insured plan's. That's why I say you need to know what each plan's COB says.

I don't know what being a non-federal government entity means or what it would have to do with this cituation?

[jeanine]

A non-federal govt entity is a state or local govt plan. These plans are exempt from ERISA. At least in Ohio, public employer plans (including above and more) are regulated under the Ohio Revised Code. Although I haven't had to decide whether this made any difference under COB, we are currently in the process of reviewing all of our self-funded public employer plans for state-mandated benefits and the new external review system in Ohio.