Coordinating benefits

What you need to know when an employee is covered by Sharp Health Plan and another health insurance plan.


When an employee is covered by Sharp Health Plan and another health plan, there is a coordination of benefits between the two plans.

The goal of this kind of coordination is to maximize coverage for allowable expenses, minimize out-of-pocket costs, and prevent any payment duplication. Total payment from all coverage should never exceed 100% of the allowable expenses. Details can be found in our recently updated Group Administration Manual.

Commercial

If the member is covered…Who pays
… as the subscriber under Sharp Health Plan and a dependent under other planSharp Health Plan
… as the subscriber under other plan and a dependent under Sharp Health PlanOther plan
… as the subscriber under both plansPlan with the earlier effective date
… as the spouse under both plans
… as a child under the same parent but two different plans

Governmental/military

Type of other coverageWho pays
TRICARE or CHAMPUSSharp Health Plan
Medi-Cal, Healthy Families, Access for Infants and Mothers (AIM)Sharp Health Plan

Medicare

If the members is/has…Who pays
If the member is working or covered as a dependent of a working spouseIf the member is covered as a retireeIf the member is covered under COBRA, Cal-COBRA or individual conversion
65 years of age or older
  • Sharp Health Plan (if 20 or more employees)
  • Medicare (if fewer than 20)
MedicareMedicare
Under 65 and disabled
  • Sharp Health Plan (if 100 or more employees)
  • Medicare (if fewer than 100)
Medicare
Medicare
 First 30 months of Medicare eligibilityAfter 30 months
End-stage renal disease (ESRD) or kidney transplantSharp Health PlanMedicare

 

Is the member a child covered under two different parents?

Then the "birthday rule" applies. The child’s primary coverage is the plan of the parent whose birthday (month and day) comes first in the year. If both parents have the same month and day of birth, then the coverage that has been in place longer is the primary.