Coordination of Benefits - Dual Coverage

[rattle28mp]

What is the name of your state (only U.S. law)? NY

Hello

I’m currently a retired federal employee. I kept the FEHB health insurance which is UHC Consumer Driven Plan option with employer (or ex-employer now) who grants a yearly HRA sum of $2400 for self plus one. After I exhaust this HRA amount I have to pay out of pocket until I meet the plan’s deductible of $3600. After I reach the $3600 deductible the plan becomes a regular fee for service plan with copays and coinsurances. This is my primary insurance.
I also have Health insurance coverage through my husband’s employer which is also UHC regular fee for service with copays and co-insurance without an HRA. This is my secondary insurance.
I recently went to my doctor and after the service I received my EOB from my primary insurance. It stated that $245 was the amount billed by my doctor. Plan discounts were $21.72. I was responsible for $223.28. My HRA then paid this out of pocket expense of $223.28 since I still had money in the HRA and I had not met the deductible. I paid $0 myself and $223 went towards my deductible.
I would like to know how the coordination of benefits would work in this instance. Can I submit a claim to my secondary insurance so that they can reimburse the amount back to my HRA or at least get some sort of credit toward my secondary insurance deductible? Would my secondary insurance be responsible for anything?
Thank you.

 

[lkc15507]

The HRA is not insurance, nor part of the health benefit plan. It is a separate program offered under separate terms and conditions as defined by your employer. In order to determine if an expense is an eligible, qualified medical expense (as defined by internal revenue code 213), you will have to refer to your employer HRA plan description.

My problem with understanding your post is that you must exhaust the HRA before beginning to satisfy the regular health plan deductible. Typically what these HRAs are designed for is to cover your out-of-pocket expenses (ie the $3600) after insurance payments. So what is below is how a typical HRA would work. (But I recommend you talk to your HR people.)

Once Insurance has paid (or not) you are entirely in control of which expenses you choose to submit for reimbursement. What you cannot do is profit from reimbursement of the combination of any / all plans available. SO, you should submit 1st to your employer group plan as primary, your spouse’s plan as secondary, and if there is any out-of-pocket remainder after both have paid, then you can submit to the HRA. (What I have zero knowledge of is what is eligible under your HRA.)

Also, keep in mind that both primary and secondary health plans are going to pay the provider. The HRA pays you. So, in your example if you submit the primary EOB to the secondary payer (provider should do this) any amounts the secondary considers eligible will be paid to the provider and you will be supplied with an EOB from the secondary. You will need to submit both the primary and secondary EOBs to the HRA for reimbursement.

 

[rattle28mp]

Hello and thank you for your response.
You are correct on how this HRA works. My deductible for this insurance policy is $3600 but $2400 would be paid by the HRA.
In the example/case I gave before I handed my provider both my primary and secondary insurance. When I received the primary insurance EOB It stated that $245 was the amount billed by my doctor. Plan discounts were $21.72. I was responsible for $223.28. My HRA then paid this out of pocket expense of $223.28 directly to the provider. The provider got paid and therefore there was a $0 balance. The amount of $223.28 went towards my primary's insurance deductible.
I called the provider to have them send the claim to my secondary insurance to get credit towards my secondary's deductible. They responded that since there was a $0 balance they wouldn't do that, so I sent the claim myself. The secondary paid the doctor again!! UHC has handled each claim I've sent them a different way. But anyway, am I wrong to assume that in this case the secondary insurance should credit my deductible by that amount or whatever they consider allowable or customary? Do they have any responsibility at all?

 

[Zelando]

Thanks for information