dual health ins confusion

[teller80]

I have a question about contractual rates and dual insurance and different co-pays. I'm having a hard time explaining myself, so please bear (not bare, lol) with me.

My husband has health insurance through his employer and is also covered by mine as a secondary.

He goes to our family doctor and the charge is $100. His insurance allows $75, so the write off amt is $25. My insurance only allows $60, with a write off of $40. But then it gets more complicated. His office visit charge on his insurance is $25, mine is only $15.

Does one write off amt trump the other? What should he pay out of pocket? I'm so confused!

 

[Pooh bear 39]

If the office visit charge is a co-pay, then he has to pay the $25.00. Your insurance won't pick that up, nor could he use your insurance because it is only secondary.

 

[LaurLaur04]

I file insurance. If he went to the office and gave both cards he should not have to pay anything if it is a simple copay. Secondary insurance would pick up the copay of the primary. With deductibles it's a whole other ball game lol if what you are asking is can he use one or the other, no. Once the secondary insurance is aware there is a primary, they won't pay a dime until the primary has paid first.

 

[scrapshappen]

Our experience with double coverage is that the secondary always picks up what the primary doesn't so we have no out of pocket expenses. However, our primary insurance is co-pay based, not deductible.

 

[seashoreCM]

Each insurance company has its own rules to deal with two or more insurance companies covering the same person or car or home, etc.

These situations are often referred to as "co-insurance" or "other insurance" (not necessarily with co-pays).

Credit card rental car coverage is a good although not universal example of secondary coverage. In practice it usually pays just your own insurance's deductible. If you did not have your own insurance of the applicable kind (such as collision) then the credit card coverage would pay the full claim.

 

[tvguy]

Each insurance company has its own rules to deal with two or more insurance companies covering the same person or car or home, etc.

These situations are often referred to as "co-insurance" or "other insurance" (not necessarily with co-pays).

This makes sense. Although in the 15 years we had dual full coverage we never paid a penny for any medical treatment despite changes in insurance companies and plans over the years.

 

[HM]

Our experience with double coverage is that the secondary always picks up what the primary doesn't so we have no out of pocket expenses. However, our primary insurance is co-pay based, not deductible.

This is how it wrks for me too.

 

[nyrebecca]

I work for a large health insurance company and have learned that all insurances differ, and your best bet is to call your insurance and ask.

The company I work for, when processing as secondary, we reimburse the copay that the primary insurance applied.

 

[r5moores]

Hi, I also work for a very large Health Insurance company. It all depends on your company, as the secondary plan, if it is a non dup plan or not, meaning non duplicating plan. What that basically boils down is, your plan will not payout more as a secondary plan then it would have had you been the primary plan. In the scenario you just provided, your plan would pay nothing because your husbands plan paid out more then your plan would have paid had it been primary

Husbands plan: Total charge $100, Allowance $75 minus copay of $25.00 Total paid by plan $50

Wifes Plan: Total Charge $100, Allowance $60 minus copay of $15 total payout would have paid out $45

so as you can see, your husbands plan would have paid out $50.00 when as is said and done, which is more than your plan would have paid had your plan been the primary payer, so no additional monies would be paid.

Most plans are non duplicating plans. Hope that helps.

 

[teller80]

r5moores - I think that is EXACTLY what is happening.

When we got the duplicate coverage on him, I thought mine would take care of his copays, etc, but it doesn't. Now I understand why. (FYI, I'm not complaining at all, I'm just making sure it's getting applied correctly).

Thank you!

 

[r5moores]

Yes, I'm pretty positive that is what is happening. Having double coverage is not always the best way to go. Really depends on both coverages and the types of plans. When it hits the secondary coverage it still has to follow the benefits of that coverage. So say his plan did not have a deductible for in network services but yours did, once it hits yours, whatever was left over to process on his, IF there was anything would have to be applied to your deductible before your plan would pay out anything, and then most likely you'd have a coinsurance amount as well, that would be if your plan paid 90/10 or 80/20, 70/30 after deductible. So in some instances it makes no sense to have double coverage, especially when you have to pay for it. If your company covers your spouse for free, then yeah, take it, but when you have to pay additional to cover them, it doesn't always make the most sense to do it. You REALLY have to know your coverage and how it works to see if it really makes sense to pay out the extra premium when most times your plan will pay little to none.

Now there may be times when your plans allowance is more and that is when your plan will start to make some payment after your husbands.

 

[clh2]

We do not EVER have double coverage. The reason - With DH's and my previous employers - each employer got to pick the rules on how dependents got covered.

DH's employer stated that for dependents - the spouse with the first birthday in the year should cover the kids if there was more than one insurance.

My employer stated that the husband's insurance would be primary for the kiddos.

Well - since my birthday is in June, and DH's is in September - DH's employer would want to be secondary for kids, and since my insurance stated that a Husband's insurance would pay first, it just seemed like the insurance companies would be pointing their fingers to the other for who was going to pay first. I never wanted to be stuck in the middle of that mess.

I do not know if companies are allowed to arbitrarily pick rules like that anymore now that the Affordable Care Act is in place...but 10 or 12 years ago - it would have been an issue for us.

 

[3boymthr]

I used to be an underwriter for several major health insurance companies as well as for an MGU (self funded health insurance plans (ERISA plans)). There is no blanket answer to this question. r5moores is mostly right and that is the most common way benefits are paid on primary vs. secondary but read the rules of primary vs. secondary coverage in your plan documents, the way it works for one plan may not be the way it works for the other and may not be as r5moores described. There are also plans that are written so that as secondary insurer they only cover benefits not covered by the primary plan, in other words, if his plan and your plan cover office visits then his plan is primary and no benefit is paid. If this is the case, amounts applied to the deductible or copays by his plan would still be owed, your insurance would not cover any of them (ETA - even if applied to deductible wouldn't even apply them to deductible as they were covered elsewhere). OTH if for example, his plan didn't cover infertility treatment and yours did then the treatments would be covered under your plan benefits. These are primarily ERISA plans that do this.

The reality may be that you might be better off financially not covering him under your plan or under his plan if you are paying to cover him on both plans. If he is covered for free under both plans then excellent other wise I'd go with only one set of coverage.

 

[3boymthr]

We do not EVER have double coverage. The reason - With DH's and my previous employers - each employer got to pick the rules on how dependents got covered.

DH's employer stated that for dependents - the spouse with the first birthday in the year should cover the kids if there was more than one insurance.

My employer stated that the husband's insurance would be primary for the kiddos.

Well - since my birthday is in June, and DH's is in September - DH's employer would want to be secondary for kids, and since my insurance stated that a Husband's insurance would pay first, it just seemed like the insurance companies would be pointing their fingers to the other for who was going to pay first. I never wanted to be stuck in the middle of that mess.

I do not know if companies are allowed to arbitrarily pick rules like that anymore now that the Affordable Care Act is in place...but 10 or 12 years ago - it would have been an issue for us.

I don't think ACA addressed primary and secondary insurance. Of course, given some opponents won their court cases against it the whole thing may be kicked to the curb anyway.