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Primary HMO/Secondary PPO - Thinking of changing before conceiving

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harmonica74

New member
What is the name of your state? California

My employer pays 100% for an HMO, but has the option to select a number of PPO plans that I would need to pay anywhere from $40 to $300/month for if I wanted to switch to PPO.

My husband has a very strong PPO plan ($0 deductible, very low out of pocket max. 100% coverage of maternity/L&D) and it is no cost to add myself as a dependent. However, his provider's policy is that if I have the option for coverage, I need to maintain that as my primary and his comes in as Secondary.

We are planning to start trying to conceive this year, and I would much, much rather go through that process on a PPO than an HMO.

From the research I've done on Primary v. Secondary coverage, I'm currently thinking it would be worth it to enroll in a PPO plan through my employer so that the Primary and Secondary work well together, since the secondary is so much stronger than my primary options.

Questions: Given that I have options for PPO to elect in to, if my secondary coverage is so much stronger, would I be able to opt in to a very cheap plan and then have my secondary kick in? Or if I chose a cheap plan with a high deductible, will I still need to cover all of the deductible before the secondary kicks in and should therefore pay for a better plan? Or am I misunderstanding the general way primary/secondary works?
 


FlyingRon

Senior Member
First off, you need to check what the rules are on changing plans. Deciding you want to become pregnant (or even doing so) is not usually a reason that lets you switch plans outside of open season.

You have to talk to each of the plans about how they handle secondary coverage. There's no official law on how this works. It's quite common for them not to pay the share that is the deductible on the other plan. And if by "high deductible" you mean an official HDHP, you need to know that any coverage that covers below the deductible (be it primary or secondary) will disqualify you for the HSA, etc...
 

ajkroy

Member
Agree with Ron. Find out from you husband's coverage how they handle something called coordination of benefits with your employer's insurance (make sure you give the plan information and not just the name of the insurance company). Then you can decide if you wish to move forward with this plan.

If they do coordinate, you might find that it is much cheaper to go with the HMO plan from your employer (though not the HDHP, most likely), but crunch the numbers for different types of scenarios (multiple ultrasounds, C-section, NICU, etc).

Good luck.
 

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