Many Florida children are covered by two health plans, for example one through each parent's job, or an employer plan plus TRICARE. Two plans can lower what you pay for ABA. They can also create "claim limbo," where each plan waits for the other and nobody pays. The fix is knowing which plan is primary, which is secondary, and what each one needs from you. This guide explains the rules.
What is coordination of benefits?
Coordination of benefits (COB) is the set of rules plans use when more than one plan covers the same person. The primary plan pays first, as if it were the only coverage. The secondary plan then looks at what is left and pays under its own rules.
Florida law requires it for most group coverage. Section 627.4235(1), Florida Statutes, says group health policies and group-type self-insurance plans delivered or issued in Florida "must contain a provision for coordinating its benefits" with other group coverage for the same loss. Florida's autism mandate also lets plans apply "coordination of benefits" to ABA (s. 627.6686(4)(d)).
When a plan reduces its payment because of other coverage, s. 627.4235(2) allows that only if "the insurers together pay 100 percent of the total reasonable expenses actually incurred" for covered services of that type. In practice, each plan's own allowed amount, deductibles and rules still shape the result, so two plans do not always mean you pay nothing.
Which plan pays first for my child?
Florida's statute lists the order for group plans that both have COB provisions. Here it is in plain language:
| Situation | Who pays first |
|---|---|
| The person is covered as an employee on one plan and as a dependent on another | The plan covering them as the employee (applies to a working teen or young adult with their own job plan) |
| A child is covered as a dependent on both parents' plans, parents married or living together | The plan of the parent whose birthday (month and day, not year) comes earlier in the calendar year |
| Both parents have the same birthday | The plan that has covered that parent longer |
| Parents are divorced or separated | First the custodial parent's plan, then the plan of the custodial parent's spouse, then the noncustodial parent's plan |
| A court order makes one parent responsible for health care costs | That parent's plan, once the plan has actual knowledge of the order |
| One plan is through a parent's active job, the other through a layoff or retirement | The active employee's plan |
| One plan is COBRA continuation coverage | The other group plan, before the COBRA plan |
| None of the above settles it | The plan that has covered the person longer |
An example of the birthday rule: if Mom's birthday is March 3 and Dad's is July 19, Mom's plan is primary for the children, no matter which parent is older. The statute also notes one wrinkle: if a Florida birthday-rule plan coordinates with an out-of-state plan that uses an older rule, and the two plans disagree, the other plan's provisions decide.
Self-funded employer plans are governed mainly by federal law and their own plan documents rather than Florida insurance law. Their COB sections often use a similar order, but read the COB section of each Summary Plan Description to be sure. See fully insured vs self-funded plans.
How does TRICARE work as a second plan?
TRICARE has its own federal rule. tricare.mil states: "By law, TRICARE pays after all other health insurance," with a short list of exceptions such as TRICARE supplement plans and certain other government programs. So if your child has an employer plan and TRICARE, the employer plan is generally primary for ABA.
TRICARE describes the process this way: your other health insurance processes the claim first, and "if your other plan doesn't cover the entire cost, file a claim with TRICARE." Active duty service members themselves are a special case; TRICARE's page explains when they may use other insurance. For family members in the Autism Care Demonstration, keep TRICARE's referral and authorization in place even when another plan is primary, and report the other insurance to TRICARE. More detail: TRICARE vs an employer plan for ABA.
Do I need prior authorization from both plans?
Often, yes. Each plan applies its own rules. If the primary plan approves ABA but the secondary plan also requires prior authorization and none was requested, the secondary plan may deny its share. Ask each plan:
- "Do you require your own prior authorization for ABA when you are the secondary plan?"
- "Is this provider in network for your plan?" An HMO or EPO secondary plan may pay nothing to an out-of-network provider.
- "Do you need the primary plan's EOB with each claim?"
- "Do you have my child's other coverage on file, with the right primary and secondary order?"
Our insurance call script has room to note both plans' answers.
How do I avoid claim limbo?
- Tell both plans about each other. Plans send "other coverage" questionnaires; answer them promptly and the same way for both. A missing or outdated answer is a common reason ABA claims stall.
- Give your provider both cards and tell them which parent's birthday comes first, or share the custody order if it assigns health costs.
- Check the first EOBs from each plan. Make sure the primary processed first and the secondary received the primary's EOB. See reading ABA codes on your EOB.
- Update after changes. A new job, divorce, remarriage, COBRA or a change to TRICARE eligibility can change the order.
- Keep reference numbers for every call, so you can show each plan what the other said.
How much will two plans actually save us?
It depends on how the secondary plan coordinates. Here is a simplified illustration, not a prediction:
Example only: the primary plan allows a set amount for a month of ABA, applies your deductible and pays its share. You still owe some coinsurance. The secondary plan then reviews that balance. If the service is covered under its plan and its requirements (such as authorization) were met, it may pay some or all of the remaining balance, up to its own limits. If the secondary plan has its own unmet deductible, it may pay less.
A common Florida situation: one parent's plan is self-funded and excludes ABA, while the other parent's plan is fully insured and covers it under the state mandate. The birthday rule may still make the excluding plan primary. In that case the primary plan denies the ABA claim as not covered, and the secondary plan reviews it under its own coverage. Ask the secondary plan how it handles services the primary plan excludes, and send it the primary plan's denial or EOB with each claim.
Ask the secondary plan to explain its COB method in writing. For the numbers, use our deductible math guide.
When should we talk to a professional?
If plans keep pointing at each other after you have updated both, call each plan's member services and ask a supervisor to coordinate directly. For fully insured Florida plans, the Florida DFS Insurance Consumer Helpline (1-877-693-5236) can help. If the dispute turns on a custody order or divorce decree, a Florida family law attorney can explain how the order applies.
How Hope Center can help
Hope Center for Behavior Change checks both plans during a free benefits check, confirms which is primary and whether each needs its own authorization, and bills them in the right order. We are in network with Blue Cross Blue Shield (Florida Blue), Aetna, Cigna (Evernorth), UMR, Personify Health and TRICARE East (Humana Military). Costs depend on your plans; self-pay with a sliding scale is available. See insurance at Hope Center, request a free benefits check, or call 561-337-8865.