Member & Provider Services Unit: Coordination of Benefits

What We Do

The Coordination of Benefits (COB) Unit works to coordinate benefit and collection practices with providers, members, and other insurance companies to ensure that Medicaid is the payer of last resort. COB is responsible for Medicare Part D casework including claims processing assistance, coverage verification, and issue resolution. The unit also works diligently to recover funds from third parties where Medicaid should not have been solely responsible. Those efforts include estate recovery, absent parent medical support recovery, casualty recovery, patient liability recovery, Medicare recovery, Medicare prescription recovery, special needs recovery, and trust recovery. The unit has been able to increase Third Party Liability (TPL) cost avoidance dollars, a direct result of ensuring that correct TPL insurance information is in the payment systems and being used appropriately.

Please note that in the Fall of 2020 the Coordination of Benefits (COB) Unit and the Provider Member Relations (PMR) Unit merged and became the Member Provider Services (MPS) Unit.  They are displayed as separate units in this scorecard due to their different lines of work.

Who We Serve

The COB Unit works with providers, beneficiaries, probate courts, attorneys, estate executors, health insurers, liability insurance companies, employers, third party administrators (tpa) and Medicare A, B, C & D plans to ensure that Medicaid is the payer of last resort and that all possible types of recovery are pursued as required by federal law.   

How We Impact

The COB Unit recovers monies that Medicaid has paid as the primary insurer in error, that Medicaid has paid for the care of a beneficiary 55 years of age of older, who received long term care services or that Medicaid has paid for care for a beneficiary with another liable third party.  The collections from the recovery processes are utilized to offset program costs in the yearly Medicaid budget. 

The COB Unit assists Medicare beneficiaries with state health/pharmacy assistance obtain their prescription medications at the pharmacy, eligibility for pharmacy assistance, premium assistance, Low Income Subsidy (LIS), Medicare buy-in, and Medicare Open Enrollment.   The assistance given by this unit saves beneficiaries monies and allows them to access necessary pharmacy medications at a reasonable cost, while at the same time it saves the State of Vermont millions.  Ensuring that beneficiaries are receiving all of the federal programs (Medicare Buy-in, LIS PART D Coverage) for which they are eligible, means the State of Vermont will not be responsible for the costs of the services/items in the Medicaid budget. 

The updates done to systems to ensure correct claims processing properly, prevents Medicaid from being the primary payer in error, saving the program hundreds of millions of dollars annually.

Action Plan

The top 2 priorities/initiatives for the COB Unit in SFY20 are: 

  • Create a sustainable process to establish a data-matching relationship with insurers and onboard two insurers.
  • Cross-train all COB staff in all the applicable processes done by each of the respective units.
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