Coordination of Benefits

[Leigh83]

California

I am covered under my husband’a insurance (united healthcare) . I got a job and signed up for insurance since it was free (Kaiser). All that time I was using insurance through my husband...including when I was pregnant and gave birth. Had no idea that I was supposed to tell the hospital I had another insurance (who doesn’t accept the other insurance I had). I had no idea there was such a thing as coordination of benefits. We are from Canada and this whole insurance thing was new to us! Anyway, a year later (still under my husbands but no longer the other insurance). I’m seeing some Reprocessing from last year’s claim...no bills yet. Will united healthcare go back and deny the benefits and we end up paying for all the bills? If so, what can I do? Will Kaiser go back and pay for some of it? I did not use Kaiser at all the entire time I had it.

 

[cbg]

They might. There's no way for anyone to say for certain without being able to read both policies.

IF UHC retracts payment, which they may or may not do, then you definitely should submit the bills to Kaiser, who may or may not pay them. I'm not just brushing you off; this really is a matter of what both policies say and I have seen it go both ways.

 

[Whoops2u]

As /u/cbg wrote, your policy(ies) will have a section that describes the coordination of benefits if you have more than one policy. You have to adhere to the entire contract. Medical insurance is not something you can pick and choose the benefits from the policy you prefer. (As to if you should be able to is a different question.) While I don't know your insurance policies, generally you will find one policy will be considered the primary plan and the other will be considered the secondary plan.

You have two issues that might help you. First is that your (probable) primary is a closed network policy. You might get the secondary to pay for any costs denied by Kaiser if UHC has a general COB that gives payment if no other policy pays. The other gets to who's policy covers the baby. Some expenses can be shifted to the baby and, there, some policies might have a birthday rule in the COB section that allows for the parent with the closest birthday to the child to be the primary coverage source.

 

[cbg]

To add to what Whoops2u is saying, With employment-sponsored coverage, it is almost always that Hubby's coverage is primary for Hubby and secondary for Wife; Wife's coverage is primary for Wife and secondary for Hubby, and the children go by whatever is specified by the plans themselves (often, but not always, the so-called 'birthday rule'). The difficulty here is timing. If UHC had determined (and how did they?) that they were secondary for these claims after only about a month, or six weeks, it would be a simple matter for them to coordinate with Kaiser and have the claims reprocessed. But every carrier has a point at which they say, "No, that claim's too old - we're not accepting it now". I've seen that point be as short as 90 days and as long as 2 years. Without knowing what the UHC policy says on reprocessing claims where they should have been secondary and paid as primary, or the point at which the Kaiser policy will consider a claim to be "overage", there's not much more we can say. Both will be specific to the individual employer; it will not be a case of "all UHC policies say this" or "all Kaiser policies cut off at that point".

In case you're wondering, employer sponsored benefits are what I do for a living.