Prepaid health care plans that meet federal legal standards for managed care plans (e.g., health maintenance organizations, provider-sponsored organizations, preferred provider organizations, or other types of network plans [except network medical savings account plans]). They incorporate cost containment and emphasize preventive care to members of the plans. Also referred to as managed care plans.

MEDICAL,USA: 1. Provision in a group health insurance policy in which two insurance carriers work together and coordinate the payment of insurance benefits so that there is no duplication of benefits paid between the primary insurance carrier and the secondary insurance carrier. The purpose of this provision is to ensure that an insured’s benefits from all insurance companies do not exceed 100% of allowable medical expenses. 2. In Medicare, the process of determining which plan or insurance policy will pay first if two health plans or insurance policies cover the same benefits, which is called a crossover claim. If one of the plans is a Medicare health plan, federal law may decide who pays first.
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A method of integrating benefits payable under more than one health insurance plan so that the insured’s benefits from all sources do not exceed 100 per cent of allowable medical expenses.
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The coordination of benefits is in most health insurance contracts and prevents overinsurance. The coordination of benefits clause determines the primary and secondary insurers. It is often employed when a couple each has group health insurance at work and each is also covered as a dependent on the other’s policy. In the absence of the coordination of benefits clause, the husband and the wife both could collect twice for one claim.For example, Bill and Mary are married and work for different firms. Each is covered by group health insurance at work and extends their coverage to the other as a dependent. This gives them double coverage. Suppose Bill has a health claim that totals $5,000. The coordination of benefits clause would declare Bill’s insurance the primary insurance and Mary’s secondary. If Bill has a $500 deductible and an 80% co-insurance, his insurance would pay $3,600 (80% of $4,500). Bill’s $900 out-of-pocket is paid by Mary’s insurance company as secondary insurer.In the absence of the coordination of benefits clause, and assuming similar policy provisions, Bill would have collected $2,200 more than his claim.

Five-digit identification numbers (55000 to 59999) of insurers of Medicare supplemental (Medigap) plans that are issued for automatic crossover of Medicare claims. As of October 1, 2007, they replaced the traditional Medigap claim-based identifiers. Also referred to as coordination of benefits agreement (COBA) and coordination of benefits contractor (COBC).

Time frame when an individual’s employer group health plan will pay first on the medical services and Medicare will pay second. If the employer group health plan does not pay 100% of the medical bills during the coordination period, Medicare may pay the remaining costs.