Coordination of Benefits By Kaiser Permanente

If you or your eligible dependents have medical coverage in addition to Kaiser Permanente, the other health care provider may have an agreement to participate in the payment of your medical expenses.

If you are also covered by another group health plan or insurance policy, Kaiser Permanente will coordinate benefits with the other plan or insurer. Under the COB rules of the California Commissioner of Corporations, Kaiser Permanente will work with the other plan or insurer to provide you with up to 100 percent of your covered medical expenses. Kaiser Permanente will decide under the COB rules, which coverage pays first, or is primary, and which coverage is secondary.

There are rules that determine which plan is primary coverage and which plan is secondary coverage.  Primary coverage is the plan that pays first, and secondary coverage is the plan that pays second.  Coordination of benefits rules have determined that if you are an employee and receive coverage from your own group insurance, then that plan is considered primary.  Alternately, if your spouse receives benefits under your group insurance plan as a dependent and he or she is covered for benefits under their own group insurance plan as an employee, then the spouses' insurance would be considered primary.

When Kaiser Permanente is secondary, your dual coverage may enable Kaiser Permanente to establish a Benefit Reserve Account for you.

The balance in your Benefit Reserve Account can be used for out-of-pocket medical expenses that were incurred during the calendar year in which services were received. To be reimbursed for expenses incurred outside Kaiser Permanente, an Explanation of Benefits from your primary coverage must be submitted. Additionally, documentation verifying payment of your or your dependent's out-of-pocket expense must be provided. To be reimbursed for Kaiser Permanente co-payments, legible receipts indicating payment must be submitted.

When a Benefit Reserve Account has been set up for you, you will be provided with details of how to obtain reimbursement from it.

Kaiser Permanente will seek reimbursement from the patient if the patient is paid by the primary coverage for services received through Kaiser Permanente.

If you have questions on how coordination of benefits will affect your coverage under this plan you should contact the Kaiser Permanente membership services department at 1-800-443-0815 or hearing and speech impaired TDD line 1-800-777-1370, or on the internet at www.kaiserpermanente.org/california.