Secondary Insurance

[Georgia9764]

I added my wife to my employers health insurance plan last spring after we were married. She has primary insurance through her employer. The insurance through my employer would be her secondary insurance.

It was my understanding that my wife would receive full benefit of my employers insurance less the amount her primary insurance covered, any remaining deductibles, etc. My insurance, or my wife's secondary insurance has better coverage.

Here is an example:

The billed amount from the doctor's office was $200.00. This was submitted to my wife's primary insurance. My wife's primary insurance, paid $57.00 of the billed $200.00. It is my understanding that under the my employers plan, because this doctor is in network, the secondary insurance would pay the agreed in-network charge for this service less the $57.00 the primary insurance has already paid, and any of the $300.00 deductible remaining. Our total out of pocket expense would be $2000.00 maximum for the calendar year under my employer's insurance plan, which is my wife's secondary insurance. The secondary insurance denying any payment beyond the $57.00 plan allowance under my wife's primary insurance. I am now being billed for the balance of the $200.00 bill or $143.00. The secondary insurance is paying nothing additional. The reason the secondary insurance is not paying anything additional is because the the Coordination of Benefits is set up as non-duplication of benefits. They use the other insurance allowed amount.

If this is truly the case, I am receiving no benefit form the secondary insurance I have been paying for. I was expecting to receive the full benefit of the secondary insurance less the amount the primary insurance already paid.

Thank you in advance for your help.

 

[ecmst12]

Does the doctor participate with the primary insurance? Was the $143 applied to deductible, or was it not paid for some other reason? Saying that the ALLOWED amount was $57 implies that nothing was applied to deductible and the primary ins paid 100% of the allowed amount. If the doctor participated, then the $143 would be contractual write-off; if not it would be patient responsibility. So your post does not make complete sense.

Now, if the primary insurance applied the $57 to deductible and the 2nd ins doesn't have a deductible (or it was already met), then the 2nd insurance would consider the $57 according to that policy - if the plan paid 100% of allowed amount for that service, they would pay all of it, if a lesser percentage then that's what they would pay.

 

[Georgia9764]

The doctor is out-of-network for the primary insurance, but in-network for the secondary insurance. The $143 remaining balance due to the doctor was not applied to the deductible of either policy. The $57.00 is listed under the "Plan Allowance" for this particular procedure. Yes, The primary insurance paid 100% of the plan allowance for out-of-network doctors. It was my understanding that the secondary insurance would then cover the balance due to the doctor. Since this doctor is in-network they have a contracted amount for this particular procedure, lees then the $200.00 billed amount, which is $147.00. The secondary insurance is an 80/20 plan with a $300.00 deductible and $2000.00 max out-of-pocket for the year. Assuming the deducible for the secondary insurance has been met, I expected the secondary insurance to cover 80% of the contracted amount between the doctor and insurance company, less the $57.00 the primary insurance already paid. As I mentioned in my earlier post, the secondary insurance will only pay up to the "Plan Allowance" of the primary plan, which was paid in full. Since this was an out-of-network doctor for the primary plan, the $143.00 is now my responsibility. Can this be true? This is just one procedure. I have a total bill from the doctor of over $14,000.00, when I had thought my max out-of-pocket expense would be $2000.00 per calendar year.

Does this help clear everything up?

My State is Connecticut.

 

[cbg]

If it was your understanding that the secondary carrier would automatically pick up the balance of everything that was not paid by the primary carrier, then your understanding was faulty. While that can happen, it is by no means guaranteed to happen.

While the terms of the policies themselves will dictate precisely how the two policies will coordinate, it is actually rather rare that a secondary policy automatically picks up all unpaid balances. What is more common is that the secondary policy pays the difference between what they would have paid, had they been primary, and what the primary policy actually paid. They are under no legal obligation to ensure that you never have any medical bills to pay.

 

[Georgia9764]

I do not expect the secondary insurance to pay on the full amount, just the portion they would have covered it they were the primary, less the amount paid by the other insurance. They will not cover anything above the amount paid by the primary insurance, which is $143.00 less then the amount the primary insurance paid.

 

[cbg]

But that's not how the coordination works. Unless the plan is written much differently than most plans, if the primary policy has already paid as much or more than the secondary plan would have paid as primary, then the secondary policy is not liable to pay anything.

 

[ecmst12]

The primary plan, though, definitely paid LESS then the secondary plan would have. Since the provider is participating with the secondary plan, it seems that they should pay according to their contract that they have with him. Did you call the secondary plan and ask about doctors who participate with them and not the primary plan? It's not like the $143 is a contractual write-off from the 1st plan, it's patient responsibility.