Help me understand dual health insurance coverage

[teller80]

My DH was downsized in January (boo) but found another job rather quickly (yay!). He has insurance through his work and is on my plan as a secondary (I have family health insurance coverage). My insurance is much better than his. Help me understand his coverage.

His office visits are $30, mine are $15.

His deductible is $2500, mine is $150; his out of pocket max is $3500, mine is $800.

Will my insurance pick up what his doesn't cover (assuming our doctors are in both networks)? Will his office visits end up being only $15?

Thanks for any inputs.

 

[HM]

He likely won't have to pay any visit co-pays.

I have had duel coverage for about 15 years now. My coverage is my primary, and my husband's family coverage is my secondary. His is much better than mine.

But, it doesn't really matter that much because my OOP costs are mininum. I never pay a visit copay. The write-down by the two insurances almost always means that together they cover the rest of the expenses for regular doctors visits and even urgent care and one ER visit I had a couple years ago. I think I've probably paid about $15-20 total last year for things that weren't covered and I think they may have been labs.

Now this year may be different. My coverage is a lot worse this year. I've already had two ER visits (haven't seen any billing on these) and multiple doctor visits that I normally wouldn't. I hope that I'm still fully covered and have no payments to make, but I don't know.

The one thing that I wish I could do differently is use my secondary insurance for the prescriptions. My copay on them is pretty high in comparison. But, they still keep it low enough it doesn't hurt.

 

[barkley]

My DH was downsized in January (boo) but found another job rather quickly (yay!). He has insurance through his work and is on my plan as a secondary (I have family health insurance coverage). My insurance is much better than his. Help me understand his coverage.

His office visits are $30, mine are $15.

His deductible is $2500, mine is $150; his out of pocket max is $3500, mine is $800.

Will my insurance pick up what his doesn't cover (assuming our doctors are in both networks)? Will his office visits end up being only $15?

Thanks for any inputs.

the way it's worked for us (IF THE PROVIDERS USED ARE BOTH IN NETWORK/CONTRACTED WITH BOTH PLANS)-

co-pays/office visits-(if no deductible applies)-his insurance gets billed first and pays all but $30, then yours gets billed and he's left w/$15.

w/stuff the deductible applies to-both insurers keep track so with his he's on the hook until he hits his $2500 for them to cover but once he's up to $150 yours should cover. out of pocket works the same (once he hits $800 yours should cover until he hits the $3500 for his at which time both will cover). it's gotten wonky with this a few times though-with one insurance company arguing that the coverage provided by another fails to meet their 'out of pocket' criteria.

it gets MUCH more complicated with plans that have different providers b/c then (we've see) our primary plan have a higher contracted rate than our secondary so once the billing through it is completed and it goes to the secondary they bounce a portion of it or just deny it outright b/c the original billed amount exceeds their contracted rate.

 

[tvguy]

It all depends on how your company's plan is written.
Many years ago DW and I had dual coverage, different employers using same insurance company. No co-pays, never paid anything
Now, my company's plan will pay for me, but because my wife has insurance....even if she doesn't sign up for it....they require a $5,000 out of pocket for her before they will start paying.
Dental is worse. Because she has an option of dental at her work, even if she does not sign up, just having the option is enough for them to deny any coverage under the family plan. They will pay for me and our DD, but nothing for my wife .

 

[supersnoop]

The term you need to understand is "coordination of benefits." I've never had to deal with it, so I don't know much about the mechanics of it, but I work closely with the health insurance industry, so at least I know what it's called.

 

[Marionnette]

Oop! Sorry, wrong thread!

 

[Snoozan]

You need to check with your health insurance to see if they have a 'duplication of coverage' clause in their plan. Some insurance companies will not pay secondary for a spouse if the spouse has their own employer sponsored health plan. This is why my husband and I kept our own individual insurances as my company would not pay for my spouse if he had his own coverage, even if I had family coverage.

 

[amylevan]

Just something to consider: My company offers a buy back. In other words, I am covered under my DH's family insurance through his work, so I can opt out of coverage from my company and take the cash.

So, if your DH's new company offers something like that, it might be beneficial since your insurance is so much better. But again, you need to read through all the paperwork to ensure that your policy would cover him if he has other options.

 

[J.Casto79]

My DH was downsized in January (boo) but found another job rather quickly (yay!). He has insurance through his work and is on my plan as a secondary (I have family health insurance coverage). My insurance is much better than his. Help me understand his coverage.

His office visits are $30, mine are $15.

His deductible is $2500, mine is $150; his out of pocket max is $3500, mine is $800.

Will my insurance pick up what his doesn't cover (assuming our doctors are in both networks)? Will his office visits end up being only $15?

Thanks for any inputs.

We had dual insurance last year but I didn't cover the family this year due to my insurance benefits being cut. My wifes open enrollment is not until the summer so I couldn't just drop mine all together and go on hers, but this is what I noticed.

1) Never pay an office copay. When your husband goes to the doctor, he shouldn't have to pay a copay. Some facilities just don't understand and will ask anyway, but you should not have to pay. They will bill his insurance company, they will adjust to their negotiated rate, pay if appropriate. Then the office will submit the bill with a copy of what was paid to your insurance.

2) Whatever his insurance doesn't pay will count towards his deductible (less his "copay") even though your insurance will be picking up some of the tab.

3) His insurance negotiated rates are the ones that count. If yours has a lower negotiated rate, yours will pay a lower amount and you will be out of pocket more.

4) You'll never ever ever understand how much you have to pay. I literally got EOB's from mine and my spouses that said they paid more than was even billed. I showed it to a lady up the street from me who works for an insurance company and she couldn't figure it out. ---You'll just end up paying whatever you get a bill from the doctor for---

 

[LaurLaur04]

I work in an urgent care in NC. I've only ever really seen this one scenario in which someone ended up having to pay if they had dual insurance. Primary plan was a deductible plan (no copays, only a deductible) and the secondary was a copay plan. They always had to pay their secondary copay until the deductible was met on the primary plan. Other than that, I don't recall seeing anyone get billed. But it really depends on the insurances.