Coordination of Benefits in Kansas

[sam_peyton]

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

Hello October is open enrollment at my husband and my employers and we are thinking about adding me as a dependent on my husband insurance, but at the same time keeping my own insurance through my employer.

The reason we are considering doing this is because we are hoping that we will be having a baby some time in 2010. His health insurance benefits are a little better than mine but my prescription and dental insurance are better than his so I would like to keep those benefits.

My insurance is through United Health Care and would be my primary
$1000 deductible
20/80 co-insurance
max of out pocket of $3500

My husband insurance is through Cigna
$500 deductible
20/80 co-insurance
max out of pocket of $3000

I have called Cigna four separate times and each time I have receive a different answer regarding how secondary benefits are determined.
I have read the SPD and the wording is rather vague and not very informative.
I have gone to the Kansas Health Insurance department website and read the laws on the subject but I am still not clear on all of the details.
The following is how I interept the data I have gathered.

If my delivery resulted in an allowable charge of $10,000 (my understand of the Kansas regulations is that if the secondary plan would have had lower allowable charge- it must still determine it benefit on what the primary plan allowed)
then first my primary insurance will pay
10,000
-1000 (my deductible)
=9000(0.8)=7200- UHC payment
leaving me with a $2800 bill (10000-7200-2800)

Then Cigna will first consider the claim as if it were my primary so
10,000
-500
=9500 (0.8)=7600 Cigna responsibility IF it were my primary.

So the difference between the two $7600-$7200= $400 that Cigna would pay leaving me with a $2400 responsibility.

Since Cigna save $7200 (would have paid $7600 but only paid $400) by not being my primary plan, the $7200 would go into my benefit reserve. Cigna will use the benefit reserve to pay for up to 100% of all allowable charges within the claims determination period.

According to this wouldn't that $7200 go towards the $2400 that would be my responsibility for the claim?

References:
Kansas regulations-from the following website
[url=http://www.ksinsurance.org/legal/regulations/Article%204/40-4-34.htm]40-4-34 Accident and health insurance;[/url]

SPD information regarding COB
"A. When this coverage plan is secondary, it may reduce its benefits by the total amount of
benefits paid or provided by all coverage plans that are primary to this coverage plan. As each
claim is submitted, this coverage plan will:
1. Determine its obligation to pay or provide benefits under its plan;
2. Determine the difference between the benefit payments that this coverage plan would
have paid had it been the primary coverage plan and the benefit payments paid or
provided by all coverage plans primary to this coverage plan.
If there is a difference, this coverage plan will pay that amount. Benefits paid or provided by this
coverage plan plus those of coverage plans that are primary to this coverage plan may be less than
100 percent of total allowable expenses.
B. If a covered person is enrolled in two or more closed panel coverage plans and if, for any
reason, including the provision of service by a non-panel provider, benefits are not payable
by one closed panel coverage plan, COB shall not apply between that coverage plan and other
closed panel coverage plans."

I may be intreputing this information incorrectly so please if you have knowledge on any of this please let me know. I can't seem to get any of Cigna customer service rep to give me a consistant answer. How this works will have a huge impact on our decision- so any help is truly appreciated.

[ecmst12]

I *think* that in your scenario, Cigna would only pay $400. The difference between their payable amount and the primary's payable amount.