Any drawback to dropping primary insurance coverage?

[Filius]

I live in California and have Anthem insurance through my employer. My wife has Kaiser through her employer. Since she has a family plan covering our two kids as well, I am automatically included in her plan.

I had been using Kaiser doctors and facilities for the past several years, not knowing that I should have been using my own Anthem-approved doctors since that is my primary plan. I like Kaiser because the co-payments are lower and there is less billing hassle since all their services are self-contained.

I was recently diagnosed with a heart condition and need to decide quickly whether I will utilize a Kaiser PCP or an Anthem one for future tests and treatment. At this point I see very little downside to giving up the double coverage and sticking with Kaiser alone, and am thinking of telling my boss to cancel my Anthem coverage immediately.

Is there a downside to to this plan that I'm not thinking of?

I would appreciate any info. Thanks.

 

[Ladyback1]

I live in California and have Anthem insurance through my employer. My wife has Kaiser through her employer. Since she has a family plan covering our two kids as well, I am automatically included in her plan.

I had been using Kaiser doctors and facilities for the past several years, not knowing that I should have been using my own Anthem-approved doctors since that is my primary plan. I like Kaiser because the co-payments are lower and there is less billing hassle since all their services are self-contained.

I was recently diagnosed with a heart condition and need to decide quickly whether I will utilize a Kaiser PCP or an Anthem one for future tests and treatment. At this point I see very little downside to giving up the double coverage and sticking with Kaiser alone, and am thinking of telling my boss to cancel my Anthem coverage immediately.

Is there a downside to to this plan that I'm not thinking of?

I would appreciate any info. Thanks.

I once had double coverage.
Went on vacation (out of home state). Youngest son ended up in ER w/ a kidney stone while on vacation. Then 4 days later, I ended up in the ER and was subsequently admitted to the hospital and was there for 3 days. (yep was not a "fun" vacation). And, as you can imagine, the bill was rather high. However, because we had double coverage, and because we had already met the deductible for the year--what the primary insurance didn't pay, the secondary insurance did. So, what would have been thousands out of pocket, we had to pay NOTHING!

I think it would be very short sighted to cancel your primary insurance because there is less billing hassles and lower co pays. ESPECIALLY if this heart condition could require extensive testing, treatment, hospital stays and/or emergency treatment.

Do you pay anything for the YOUR insurance coverage?

 

[Filius]

Ladyback:

Thanks for the advice, but I don't see how I could end up paying thousands out of pocket since Kaiser's deductible for hospitalization is only $250. My primary insurance is on me alone, so the possibility of my wife and kids getting sick or injured is not pertinent.

Therefore, it looks like the only upside to the double coverage is possibly not having to pay the $250 if I'm hospitalized. But I would likely save enough in lower co-payments (not to mention time spent in billing hassles) to make up for that.

[Edit] My coverage is free to me.

 

[ajkroy]

If this is not your company's open enrollment time, you cannot drop your coverage until the next open enrollment or a qualifying event (such as a birth, divorce, adoption, etc).

Ladyback's experience could be yours, too. If the two plans coordinate properly, you may not have to pay anything for copays or prescriptions.

You might also get a nasty surprise one day if your wife's insurance finds out that they have been paying as primary when they should have been paying as secondary all along; they could take back most of the money they paid out. It is your responsibility to know your insurance coverage and utilize it correctly.

 

[Filius]

If this is not your company's open enrollment time, you cannot drop your coverage until the next open enrollment or a qualifying event (such as a birth, divorce, adoption, etc).

My office administrator checked with our broker and they said I can drop it any time since I'm not paying for it.

Ladyback's experience could be yours, too. If the two plans coordinate properly, you may not have to pay anything for copays or prescriptions.

I don't see how that could work. Kaiser won't pay anything for out-of-network treatment, and Anthem won't approve Kaiser providers for treatment, other than emergencies. So if I got to an Anthem provider Kaiser pays nothing, and if I go to Kaiser Anthem pays nothing, plus Kaiser (I assume) would refuse to pay since they would say that I should have used Anthem.

It is your responsibility to know your insurance coverage and utilize it correctly.

That's easy to say, but I don't know how a layperson is supposed to know this is even an issue that he needs to look into. I have spoken with an attorney friend, as well as a doctor (earlier today in fact), and both of them said that they believed I could use whichever insurance I chose. I realize they're wrong, the point is that even intelligent, well educated people make this assumption. We can't all be expected to be knowledgeable in this area, and it's neither realistic nor fair, in my opinion, for insurance companies to hold us to that standard.

 

[ajkroy]

Whether you pay your premiums or your employer does, it doesn't affect the open enrollment period. There are few and very limited special circumstances that you could drop insurance outside of open enrollment (unless you are planning to terminate employment) even if you are enrolled on the exchange. Unless we are talking Medicaid, Medicare, or Tricare, you are most likely going to have Anthem as your primary insurance until the next open enrollment period. Check with your employer -- it might not be too far away.

It is up to you which plan you use, but be aware that if you are required to use Anthem providers and you do not or you are required to obtain a referral and you do not, you could end up with a whopper of a bill down the line. Even if Kaiser pays now, they can still take back that money years later and leave you on the hook.

Each member is given a large amount of information when joining a new insurance plan and usually every year thereafter. Anthem also has a toll-free number you can call and ask them any question about your plan utilization. If you didn't read it or understand your contract with your insurance provider, that is hardly your insurer's fault.

For future reference (in most circumstances with private insurances): your plan is your primary, your spouse's plan is their primary, you are each other's secondary. Kids have the insurance of the parent who has the birthday first in the calendar year as their primary. This does not apply to Medicare/Medicaid/Tricare.

 

[Filius]

I know that we're given a large amount of information. The question, to me, is the extent to which the average person should be expected to grasp the meaning and significance of all of it, even after having read it. Do you really think the average high school graduate, or for that matter high school dropout, would understand most policy provisions on coordination of benefits?

In any other area of life, if you pay for service with one company, and then pay for it with another, you can use either one at your option. How are laypersons supposed to know, or even suspect, that you can't do this with insurance?

If the insurance companies are going to be so particular about refusing to pay, then they should also be particular about making sure what insurance you have and don't have when you go in for service. I don't recall anyone at Kaiser ever asking me if I had other insurance. Heck, even the hospital didn't ask (when I was admitted last weekend); it only came up because my wife mentioned it.

Besides, if they are going to reduce the amount they pay based on me having other insurance, shouldn't they also reduce the amount of our premiums based on me having other coverage? If Kaiser is practically useless to me because I have Anthem, then why charge us for it at all?

 

[Just Blue]

Ladyback:

Thanks for the advice, but I don't see how I could end up paying thousands out of pocket since Kaiser's deductible for hospitalization is only $250. My primary insurance is on me alone, so the possibility of my wife and kids getting sick or injured is not pertinent.

Therefore, it looks like the only upside to the double coverage is possibly not having to pay the $250 if I'm hospitalized. But I would likely save enough in lower co-payments (not to mention time spent in billing hassles) to make up for that.

[Edit] My coverage is free to me.

Then why are you asking this question??

 

[ajkroy]

I know that we're given a large amount of information. The question, to me, is the extent to which the average person should be expected to grasp the meaning and significance of all of it, even after having read it. Do you really think the average high school graduate, or for that matter high school dropout, would understand most policy provisions on coordination of benefits?

In any other area of life, if you pay for service with one company, and then pay for it with another, you can use either one at your option. How are laypersons supposed to know, or even suspect, that you can't do this with insurance?

If the insurance companies are going to be so particular about refusing to pay, then they should also be particular about making sure what insurance you have and don't have when you go in for service. I don't recall anyone at Kaiser ever asking me if I had other insurance. Heck, even the hospital didn't ask (when I was admitted last weekend); it only came up because my wife mentioned it.

Besides, if they are going to reduce the amount they pay based on me having other insurance, shouldn't they also reduce the amount of our premiums based on me having other coverage? If Kaiser is practically useless to me because I have Anthem, then why charge us for it at all?

But I bet Kaiser DID ask you if you had other coverage and I'm almost certain Anthem did. And probably every single year, too. You are supposed to tell them that you have other coverage. It is part of your contract.

Kaiser doesn't base their premiums on whether or not one member's spouse has other insurance coverage; they rate the entire company as a whole, usually based on the past five years of claims and the population of the employees. Then the premiums are negotiated with the company representative based on decrements (copays, deductibles, prescription costs, imaging costs, etc). I guarantee that *you* were not factored in, unless you had cost the insurer a lot in claims in recent years. Besides, you aren't being charged any extra money for either plan that you are on. Your wife pays for the family plan and yours is no cost to you.

Look, I get that you didn't understand this in the beginning...but I am trying to teach you. You can save or spend money at your whim. At least now you can't claim you didn't know.

 

[Filius]

"Look, I get that you didn't understand this in the beginning...but I am trying to teach you. You can save or spend money at your whim. At least now you can't claim you didn't know. "

Of course, and I appreciate it. I'm not arguing with you personally, but I did feel somewhat defensive when you implied that I had no excuse for not knowing.

As for Kaiser asking, I'm telling you they absolutely did not. When my wife mentioned -- unasked -- that I had insurance through my job, this was at the end of the process, when all the paperwork was done and they were asking if we wanted to pay the deductible now or when I'm discharged. Then the woman said, "Oh! well that changes everything," and so forth, which is the only reason I'm now aware of the issue.

 

[Filius]

Then why are you asking this question??

Because my "free" insurance is more expensive and troublesome to use than my wife's insurance.

 

[Filius]

Kaiser doesn't base their premiums on whether or not one member's spouse has other insurance coverage; they rate the entire company as a whole, usually based on the past five years of claims and the population of the employees. Then the premiums are negotiated with the company representative based on decrements (copays, deductibles, prescription costs, imaging costs, etc). I guarantee that *you* were not factored in, unless you had cost the insurer a lot in claims in recent years.

Well then if the premiums are based on the rating of the entire company as a whole, and doesn't factor in my personal situation, then they should also pay the benefits without factoring in my personal situation. Evidently they take the broad view when collecting money, but become very particular when paying it out.

Besides, you aren't being charged any extra money for either plan that you are on. Your wife pays for the family plan and yours is no cost to you.

Maybe in theory, but n reality my money is my wife's, and vice versa. We made the decision to get the family plan through her job instead of mine because it was cheaper. We pay extra to have it cover me and our kids rather than her alone. (There was no option to cover her and the kids but not me for a lower price; if there was, we would have done that.)

 

[cbg]

When you say the coverage is free to you, do you mean that the company pays 100% of the premium? There are no deductions taken from your paycheck at all, ever? Does the same apply to all employees? Does it matter if they are covering dependents or not?

I'm not saying you're wrong; I'm making sure I understand you correctly, because Federal law dictates when you can and cannot drop coverage and it's a very important point.

 

[ajkroy]

Exactly. Your wife is covering the kids and you are included at no extra cost. Notice that it doesn't matter if you have one child or as many as the Duggars, it's the same cost for a family plan. Some plans have "member + one" and "member + more" plans, but it doesn't appear that your wife's plan does.

And if you'd like to try to change how healthcare works in America, you'll have to get in a very long line.

 

[Filius]

When you say the coverage is free to you, do you mean that the company pays 100% of the premium? There are no deductions taken from your paycheck at all, ever? Does the same apply to all employees? Does it matter if they are covering dependents or not?

Yes, the company pays 100%, no deductions from my paycheck. Same for all employees. We have to pay if we want our dependents covered.