Texas General Lines — Life, Accident, Health and HMOTexas Statutes and Rules Specific to Accident, Health and HMOHard
A group health insurance policy in Texas includes a coordination of benefits (COB) provision. An insured individual has coverage under two group plans: Plan A as an employee and Plan B as a dependent of their spouse. If the individual incurs medical expenses, which plan is typically considered primary under the standard COB rules in Texas?
- AThe plan that offers the most comprehensive benefits.
- BPlan A, as it covers the individual as an employee (their own coverage).
- CPlan B, as it covers the individual as a dependent.
- DThe plan that has been in effect for the longest period.
Show answer & explanationAnswer & explanation
Correct answer: B. Plan A, as it covers the individual as an employee (their own coverage).
Under standard COB rules, when an individual is covered by two group plans, the plan covering the individual as an employee (their own coverage) is typically primary over the plan covering them as a dependent.
Why the other options are wrong
- A. Benefit comprehensiveness is not a standard COB determinant for primary/secondary status.
- C. Dependent coverage is usually secondary to an individual's own employee coverage.
- D. Length of coverage is a COB rule for when a person has two plans in the same capacity (e.g., two employee plans), but not when one is employee and one is dependent.
COB (Coordination of Benefits) 'Own Coverage' Rule
In group health insurance, when an individual has coverage under two plans, the plan covering them as an employee (their own coverage) is typically primary over a plan covering them as a dependent.
- Applies to group health insurance.
- Determines which plan pays first.
- Own employee coverage is primary to dependent coverage.
Memory trick: Your 'own' job 'plan' always comes 'first' in the 'COB' line.