Dual Coverage - Pls help - Primary Policy has high deductible

[Sandy_R]

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

Hi, I am not sure how dual health insurance coverage works when my primary policy has a deductible of $2500 for everything other than office visits and prescriptions and my secondary policy has much better coverage without a deductible or with a low deductible. I don't know if I have to pay the $2500 deductible on my primary policy to access most of the services available to me without a deductible or with a much lower deductible.

The first policy is a high deductible PPO plan I would not be carrying if my second policy, a student health insurance plan, covered my monthly prescription costs adequately. With the exception of prescriptions, the student health insurance policy covers more, has no deductible for most services and charges a $200 deductible for services (specialists, tests and procedures) outside the university system. However, the university says it is secondary to any other health insurance policy I might carry. Again, the only reason I carry the "first" policy is because the university health system does not cover my prescription costs adequately - it caps prescriptions at $2000/year and my prescription costs run far higher (Unfortunately, a "prescription only plan is not an option for the medications on the primary policy).

More info:

For the last year and a half, I have been using "both" policies simultaneously - as if neither policy were primary. Despite the fact that the same insurance company provides both policies, I have not received any notice that I am doing something wrong. I get checkups and referrals to doctors outside of the system through the university policy, and buy my prescriptions with my other [what, should, in theory, be the primary] insurance policy. I realize I am not doing this correctly and that I will either pay far more, or far less, if I use the policies as intended under dual coverage. The same insurance company issues both policies (which are as different as one could possibly imagine).



Questions/Concerns - Please help
My concern is the $2500 deductible on my "primary" health insurance policy. Do I have to pay $2500 (or a portion of this deductible) before I can access services on my secondary policy that do not have a deductible, only have a $200 deductible, or are not covered under my primary policy? I cannot figure this out, and it's the reason I have not used the two policies as if I had dual coverage. This may not be an option any longer since I see a specialist (which I have paid for with the non-university policy, and the insurance company recently re-routed my claim on my "primary" policy back to the university (supposedly the secondary policy - they didn't send me anything about using my policies incorrectly however). I have been able to pick up my prescriptions as usual.

The big question is how does the large deductible on the primary policy affect my coverage and access to care under the secondary policy? If I did not have to carry the first policy to buy prescriptions each month, I would not have a huge deductible to satisfy before using what is covered by the university at a much lower cost (and for a few services, a much lower deductible). I don't want to ask the insurance company or the university since I have been using both policies without a problem for over a year. I will only have the university health insurance for 3 more months. If more information would be helpful, please let me know.

If you can only answer one question, the following would be most helpful to me:

To use my secondary policy (the university health system) for services that my primary policy charges a $2500 deductible, do I have to pay the deductible on the primary policy first?

If you don't know the answer, can you suggest a cheap, reliable/accurate source of information on this? As a graduate student with an chronic medical condition, I am low on funds.

Thank you in advance for any help you can provide.

Gratefully,

Sandy,
In California

[cbg]

To a point, your primary and secondary policy are independent of each other.

I can't tell you exactly how it will work because the exact details depend on the wording of the policies themselves. However, for the most part, it works like this:

1.) You incur the services.

2.) The bill is sent (either by you or by the provider) to the primary carrier.

3.) The primary carrier makes payment based on the terms of the policy. This may involve applying the bill to the deductible, it may mean issuing a check, or it may mean outright denial if the service is not covered under the primary plan.

4.) The bill, along with the EOB from the primary carrier, is sent to the secondary carrier.

5.) The secondary carrier makes payment according to THEIR plan. Most will only require that you have fulfilled THEIR deductible before they will make payment, not that you have fulfilled the primary carrier's deductible, but again that will depend on the wording of the policy itself.

At no time with the two carriers pay more than the total amount of the bill; in fact, you can still be left with a balance to pay even after both carriers have made payment. For the most part, it generally works like this:

1.) For easy arithmetic, let's assume that the bill is for $100.

2.) The primary carrier makes payment in the amount of $80, leaving a $20 balance.

3.) The secondary carrier will look at what they would have paid, HAD THEY BEEN the primary carrier.
3a.) If they would also have paid $80, they will pay nothing
3b.) If they would have paid $90, they will pay $10
3c.) If they would have paid the full $100, they will pay the $20 balance
3d.) and so on.

There are always variations on a theme, but that's generally how it goes.

However, the ONLY place to get a DEFINITE answer to your question is by reading the policies. I've given you how it usually works, but this is not a question addressed by law. It is addressed by the policies directly.

[Sandy_R]

CBG,

Thank you for the help. I will try to get a copy of the university's health insurance plan. I have a list of what they cover, but do not have the detailed policy rules explanation and am not sure where to get them without explaining that I am carrying two policies.

It should not cost me *more* to have dual coverage! If If the deductible of $2500 on the primary policy has to be paid before the secondary policy kicks in, this means I pay much more for health benefits because of my coverage.

Thank you again for your help.

Sandy

[cbg]

In general, it is not cost effective to have two coverages. Unless the secondary carrier has much better benefits than the first carrier, generally when you factor in the two premiums and the applicable deductibles and co-pays, you're usually just as well off with one as too.

[thedoctorisin]

In case you want to do further research on Google or anywhere else, the term is "coordination of benefits".

[ecmst12]

If your doctors are willing to bill both insurance companies, then that may be what they have been doing all along. Until the primary deductible is met, then this is ideally how it will work:
1. Doctor bills primary insurance. Primary insurance figures out what the allowed amount will be, and applies that entire amount to your deductible. Primary insurance sends EOB to doctor.

2. Doctor sends bill to 2nd insurance with EOB from 1st insurance. 2nd insurance sees primary pays nothing. MOST LIKELY they will pay based on the policy rules but using the allowed amount determined by the primary policy, unless their allowed amount would be less. If the doctor participates with both plans, then there will be no problem either way. 2nd policy sends payment to doctor with their EOB.

3. Doctor bills you for anything remaining.

After your deductible is met, the 2nd policy will probably be paying little or nothing, but t that's not why you have it, you have it for that first $2500 that your primary doesn't pay.

[Sandy_R]

Thanks again for the help and tips. I would rather not bring the other policy (what they have decided is the primary policy) to the university's attention until I know whether or not I have to meet the $2500 deductible before I can receive the university's benefits. I am simply not sure how to find out how the university's policy works. There doesn't appear to be detailed policy available online or in the handouts I have been given that describes how the coordination of benefits works.

If the university had better prescription coverage (my prescriptions cost $1500/month), I would not carry the other policy while enrolled. Any ideas on how to get this information without informing the university that I carry another insurance policy? They will ask me to identify myself if I call. Ironically, the insurance carrier is the same for both policies. The university's policy is far superior *except* for prescription coverage.

Regards,
Sandy

[cbg]

Um, Sandy, I hate to tell you, but they are entitled to the information that you have other coverage.

[ecmst12]

What you are doing now is defrauding both insurance companies. You need to come clean with both companies NOW. Yes, it will cause a big mess, but anything else would be illegal and will cause you bigger problems in the long run.

[momm2500]

i think you need to check the wording of the high deductible plan. SOMETIMES a group plan looks at a student plan as an individual plan and does not coordinate benefits. Some student plans will not pay anything till it goes through the group plan.

my experience. both hubby and self had full family group coverage thru our employers. child went away to college and it was mandatory that all students have student health insurance no matter what the parents had. it did cost me an extra $183 a year but ended up being worth it. kid got hurt in a game and my insurance paid what they could. hubby's plan paid nothing cause they were not part of the HMO but the school insurance picked the balance up.

so you do need to read into both policies and see what they say.