Health Insurance - Dual Coverage Question

[s0me0nesmind1]

Hey folks - Going through the annual job benefits enrollment right now and had some questions. I know we have a few people here who work in healthcare bizz - and probably others that are just better informed than me on health insurance.


What employers have been doing a lot lately: Imposing a "Surcharge" for covering your spouse if your spouse has coverage at their employer. Now personally - I'm not aware of a way for them to go to you and demand that you give them your spouse's employer and investigate if they do in fact have insurance options or not... But I'm not looking to risk potential insurance fraud.

But in my selection this year I saw where there is a clause for


So let's say for instance I sign up for dual coverage - one under my employer - and also family coverage under my spouse's.

• My primary insurance has a deductible of $2,500
• My secondary insurance (my spouse's) has a deductible of $2,000.
• Overall, the "spousal surcharge" fee is $1,200 - whereas I could just get insurance under my employer, have dual coverage with my spouse's, and not pay the surcharge.

How would it work if I.... say.... fill a prescription for $800 each month every month?
Or go to the doctor for a $200 visit?
Will my payment fill the deductible buckets of BOTH insurances, or only one first, then the next one has to get filled?


Overall just trying to understand if it's potentially worth having dual coverage.

 

[dyna]

My guess is that both deductibles would be completely independent.

I'm sorry you are in this dilemma, it is total BS. I had a similar scenario when we had our first child and the question was which insurance does our kid go on. It ended up being pregnancy/birth on wife's insurance then after our daughter was born, it went on my family plan.

 

[dullard]

Overall just trying to understand if it's potentially worth having dual coverage.

I am not an expert on this by any means. But, I thought you could only apply a health care event/expense to one insurance. So basically, you end up paying both premiums, both deductibles, but only get coverage from one insurance when they do finally pay out. Ultimately, if I understand correctly, you get the worst of all worlds that way. I could be wrong though.

My wife and I just both get single insurance coverage from each employer. Cheapest way for us.

 

[purbeast0]

Threads like this make me realize how grateful I am for my health insurance through my employer.

 

[pcgeek11]

I can't speak specifically for your situation, but I have three health insurance plans and everything I pay counts towards the deductible on all of them.

Employer Plan, Medicare Plan A and B and Tricare for life ( which also acts as Gap and Advantage plan and pays medicare cost shares and deductibles ).

 

[deadlyapp]

I can't imagine that a payment would be applied to both insurances. My understanding would be that whichever insurance you used at time of service would be used and that payment would apply to that specific deductible, and each insurance programs would work completely independently.

I can't see any time that dual coverage would be beneficial unless your plans have certain limits for what they'll cover, but it seems like you'd have to have consistent, expensive health care costs to defray the cost of a second plan.

 

[sactoking]

It's a bit complicated, I'll try to explain as clearly as I can.

First off, when you have dual coverage you have to understand which coverage is primary and which is secondary. Generally coverage in which you are the named insured is your primary and coverage in which you are a spouse/dependent is secondary. Things like Medicare, Tricare, etc. can mess this up but for private coverage this is generally true. In your scenario then your employer coverage is primary and your spouse's is secondary. This is important because providers won't (and often can't, by contract) submit the claim to multiple insurers. They are bound to only submit your claim to your primary coverage.

So you have an appointment, say a $200 office visit, and the office will submit the claim to your primary insurance. Your insurance carrier will adjudicate the claim per your coverage and issue you an Explanation of Benefits (EOB) describing how the claim was handled. You can then submit the claim to your secondary insurance and they are bound, by law, to adjudicate the claim as if no other coverage existed. In other words, they handle the claim "fresh." Then, once the final determination is made, they offset any benefit the secondary coverage would pay by the amount of benefit the primary coverage paid.

In your scenario, your primary insurance would get the $200 office visit bill. They apply their contracted rate (say, $60) then check it against your deductible. Assuming the deductible hasn't been met they allot the $60 to the deductible and send you an EOB that lists billed charges ($200), allowed charges ($60), amount you owe ($60), and deductible accumulated ($60/2500). You could then send the office visit bill for $200 to you secondary insurance. They apply their contracted rate (say, $55) then check it against your deductible. Assuming the deductible hasn't been met they allot the $55 to the deductible and send you an EON that lists billed charges ($200), allowed charges ($55), amount you owe ($55), and deductible accumulated ($55/2000). Even though you owe $55 per the EOB you'd actually owe the $60 under the primary insurance.

Later in the year let's assume you have another $200 office visit after several other expenses. This time your primary insurance has $2200 built up toward the deductible and the secondary insurance has $2000 toward the deductible (since they accumulate at different rates based on contracted rates). Your primary insurance will say the deductible hasn't been met and it will adjust your deductible accumulator to $2260/2500 and pay nothing. Your secondary insurance deductible HAS been met so they pay 80% of the $55 ($44 total) and you owe the other $16 ($60 contracted rate under primary insurance less $44 secondary payment).

Later in the year let's assume you have another $200 office visit after several other expenses. This time both deductibles have been met. Your primary insurance will adjust the $200 charge to $60 based on contract rates. Then they pay 80% of the $60 ($48 total). Your secondary insurance pays 80% of the $55 contracted rate ($44 total) but offsets that by the fact that only $7 remains under their contract ($55 rate less $48 paid by primary). The secondary insurer pays $7 and you're left with $5 to pay.

You could say, "That seems stupid. How will they know which one is primary vs secondary?" When you sign up for insurance you're required to disclose any other coverage you may have. If you try to hide other coverage that's fraud and it's one of the few things which might get your coverage rescinded.

Also, what's the "spousal surcharge?" I've not encountered that in the third-party plans I've administered. Is it added to the deductible? Is it a lump-sum penalty you have to pay?

 

[overst33r]

We signed up for double insurance in the year our kids were born. The amount billing errors we had to deal with as a result of coordination of benefits with facilities and providers was a royal pain in the ass. Unless you can clearly model a savings to you and are ready and willing to deal with billing errors because they will happen, I would not double insure.

 

[s0me0nesmind1]

It's a bit complicated, I'll try to explain as clearly as I can.

First off, when you have dual coverage you have to understand which coverage is primary and which is secondary. Generally coverage in which you are the named insured is your primary and coverage in which you are a spouse/dependent is secondary. Things like Medicare, Tricare, etc. can mess this up but for private coverage this is generally true. In your scenario then your employer coverage is primary and your spouse's is secondary. This is important because providers won't (and often can't, by contract) submit the claim to multiple insurers. They are bound to only submit your claim to your primary coverage.

So you have an appointment, say a $200 office visit, and the office will submit the claim to your primary insurance. Your insurance carrier will adjudicate the claim per your coverage and issue you an Explanation of Benefits (EOB) describing how the claim was handled. You can then submit the claim to your secondary insurance and they are bound, by law, to adjudicate the claim as if no other coverage existed. In other words, they handle the claim "fresh." Then, once the final determination is made, they offset any benefit the secondary coverage would pay by the amount of benefit the primary coverage paid.

In your scenario, your primary insurance would get the $200 office visit bill. They apply their contracted rate (say, $60) then check it against your deductible. Assuming the deductible hasn't been met they allot the $60 to the deductible and send you an EOB that lists billed charges ($200), allowed charges ($60), amount you owe ($60), and deductible accumulated ($60/2500). You could then send the office visit bill for $200 to you secondary insurance. They apply their contracted rate (say, $55) then check it against your deductible. Assuming the deductible hasn't been met they allot the $55 to the deductible and send you an EON that lists billed charges ($200), allowed charges ($55), amount you owe ($55), and deductible accumulated ($55/2000). Even though you owe $55 per the EOB you'd actually owe the $60 under the primary insurance.

Later in the year let's assume you have another $200 office visit after several other expenses. This time your primary insurance has $2200 built up toward the deductible and the secondary insurance has $2000 toward the deductible (since they accumulate at different rates based on contracted rates). Your primary insurance will say the deductible hasn't been met and it will adjust your deductible accumulator to $2260/2500 and pay nothing. Your secondary insurance deductible HAS been met so they pay 80% of the $55 ($44 total) and you owe the other $16 ($60 contracted rate under primary insurance less $44 secondary payment).

Later in the year let's assume you have another $200 office visit after several other expenses. This time both deductibles have been met. Your primary insurance will adjust the $200 charge to $60 based on contract rates. Then they pay 80% of the $60 ($48 total). Your secondary insurance pays 80% of the $55 contracted rate ($44 total) but offsets that by the fact that only $7 remains under their contract ($55 rate less $48 paid by primary). The secondary insurer pays $7 and you're left with $5 to pay.

You could say, "That seems stupid. How will they know which one is primary vs secondary?" When you sign up for insurance you're required to disclose any other coverage you may have. If you try to hide other coverage that's fraud and it's one of the few things which might get your coverage rescinded.

Also, what's the "spousal surcharge?" I've not encountered that in the third-party plans I've administered. Is it added to the deductible? Is it a lump-sum penalty you have to pay?

Pretty much what I expected.

Now let me throw a twist in here for you:

• Same scenario in insurances (deductibles ,etc.)
• But I have a $900/month prescription medication. On top of that - for the first 3 months, I get $500 off the fill from the manufacturer. Every month thereafter I get ~$100 off from the manufacturer.
• So currently right now with just 1 insurance - each time I pick up the prescription it records $900 on my deductible, even though I only effectively paid $400. Same goes for the next 3 months, and then $100 thereafter.

At the end of the year, does this sound like something that would be worth having? Personally I like family plans because it helps eat up the deductible for the whole family - instead of just me.



Also - concerning the "Spousal surcharge" here is an excerpt from my wife's benefits site to explain it. This is now pretty common and I would venture to say that more employers are doing this every year. Both my wife's has this - as does my employer as well.

** <company> employees who enroll a working spouse in <company> medical coverage may pay a $100/month surcharge. Please review the below information and select the appropriate option.

You ARE NOT subject to the working spouse charge if ANY of the following is currently true:

• your spouse is not employed (OR)
• your spouse is not offered medical coverage through their own employer (OR)
• your spouse is offered medical coverage through their own employer and has elected such coverage (this will be their primary coverage) (OR)
• your spouse has other medical coverage besides <company's> (i.e. Medicare, Tricare) that will be their primary medical coverage (OR)
• your spouse is a <company> employee.

You ARE subject to the working spouse charge if:

• Your spouse is offered medical coverage through their employer but has waived such medical coverage

Based on the information above I certify that:

 

[pcgeek11]

It's a bit complicated, I'll try to explain as clearly as I can.

First off, when you have dual coverage you have to understand which coverage is primary and which is secondary. Generally coverage in which you are the named insured is your primary and coverage in which you are a spouse/dependent is secondary. Things like Medicare, Tricare, etc. can mess this up but for private coverage this is generally true. In your scenario then your employer coverage is primary and your spouse's is secondary. This is important because providers won't (and often can't, by contract) submit the claim to multiple insurers. They are bound to only submit your claim to your primary coverage.

So you have an appointment, say a $200 office visit, and the office will submit the claim to your primary insurance. Your insurance carrier will adjudicate the claim per your coverage and issue you an Explanation of Benefits (EOB) describing how the claim was handled. You can then submit the claim to your secondary insurance and they are bound, by law, to adjudicate the claim as if no other coverage existed. In other words, they handle the claim "fresh." Then, once the final determination is made, they offset any benefit the secondary coverage would pay by the amount of benefit the primary coverage paid.

In your scenario, your primary insurance would get the $200 office visit bill. They apply their contracted rate (say, $60) then check it against your deductible. Assuming the deductible hasn't been met they allot the $60 to the deductible and send you an EOB that lists billed charges ($200), allowed charges ($60), amount you owe ($60), and deductible accumulated ($60/2500). You could then send the office visit bill for $200 to you secondary insurance. They apply their contracted rate (say, $55) then check it against your deductible. Assuming the deductible hasn't been met they allot the $55 to the deductible and send you an EON that lists billed charges ($200), allowed charges ($55), amount you owe ($55), and deductible accumulated ($55/2000). Even though you owe $55 per the EOB you'd actually owe the $60 under the primary insurance.

Later in the year let's assume you have another $200 office visit after several other expenses. This time your primary insurance has $2200 built up toward the deductible and the secondary insurance has $2000 toward the deductible (since they accumulate at different rates based on contracted rates). Your primary insurance will say the deductible hasn't been met and it will adjust your deductible accumulator to $2260/2500 and pay nothing. Your secondary insurance deductible HAS been met so they pay 80% of the $55 ($44 total) and you owe the other $16 ($60 contracted rate under primary insurance less $44 secondary payment).

Later in the year let's assume you have another $200 office visit after several other expenses. This time both deductibles have been met. Your primary insurance will adjust the $200 charge to $60 based on contract rates. Then they pay 80% of the $60 ($48 total). Your secondary insurance pays 80% of the $55 contracted rate ($44 total) but offsets that by the fact that only $7 remains under their contract ($55 rate less $48 paid by primary). The secondary insurer pays $7 and you're left with $5 to pay.

You could say, "That seems stupid. How will they know which one is primary vs secondary?" When you sign up for insurance you're required to disclose any other coverage you may have. If you try to hide other coverage that's fraud and it's one of the few things which might get your coverage rescinded.

Also, what's the "spousal surcharge?" I've not encountered that in the third-party plans I've administered. Is it added to the deductible? Is it a lump-sum penalty you have to pay?

Strange I haven't had any issues at all with my coverage. I usually pay next to nothing after the doctor files with all three...

 

[snoopy7548]

Threads like this make me realize how grateful I am for my health insurance through my employer.

Also why I'm grateful I don't have a spouse or kids!

 

[PowerEngineer]

It has been a while since we had dual health coverage, but I remember it working the way that sactoking described. The deductible for each plan is tied to your out-of-pocket expenses and so any cost you pay should logically count against the deductible limit in both plans.

The value of dual coverage depends quite a lot on the quality of the two plans. Obviously if the coverages are very similar then the secondary coverage will not benefit you much. Some companies offer you cash payments for declining to sign up for health care coverage, and is perhaps something to look into.

 

[purbeast0]

Also why I'm grateful I don't have a spouse or kids!

Having a spouse + 2 kids doesn't make any difference for me insurance wise, other than I guess it's a higher deductible but I don't know what it would be for single.

 

[thestrangebrew1]

I'm double covered with my employer as the primary and my wife as the secondary. No deductible for either, so I usually just pay the copay or don't depending on who/what I'm going for. I just always assumed whatever my primary doesn't pick up, the secondary picks up. I'm also double covered for dental and vision. Vision is nice because I can get contacts 1 year and get new glasses the following year and pay little out of pocket unless I go with more expensive frames or lenses. I'm the only 1 double covered in my family for health. It's too expensive to add the wife and kids under my plan, but my wife's a teacher so she gets great family plan benefits. It costs next to nothing to add spouse and kids to her plan, whereas mine it's almost $900/mo now (something like $400+/check).