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 Group Administration Manual.

Commercial

If the member is covered …	Who pays
… as the subscriber under Sharp Health Plan and a dependent under other plan	Sharp Health Plan
… as the subscriber under other plan and a dependent under Sharp Health Plan	Other plan
… as the subscriber under both plans	Plan 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 coverage	Who pays
TRICARE or CHAMPUS	Sharp Health Plan
Medi-Cal, Healthy Families, Access for Infants and Mothers (AIM)	Sharp Health Plan

Medicare

If the member is/has …	Who pays
If the member is/has …	If the member is working or covered as a dependent of a working spouse	If the member is covered as a retiree	If 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)	Medicare	Medicare
Under 65 and disabled	Sharp Health Plan (if 100 or more employees) Medicare (if fewer than 100)	Medicare	Medicare
	First 30 months of Medicare eligibility		After 30 months
End-stage renal disease (ESRD) or kidney transplant	Sharp Health Plan		Medicare

Questions? Contact us

Coordinating benefits

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

Commercial

Governmental/military

Medicare

Is the member a child covered under two different parents?

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