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Health Insurance: Frequently asked questions

Question:

My husband and I both have health insurance concurrently. I believe that my husband's policy is primary because he was born earlier in the year. His insurance company tells me that this would be the case only for coverage for children. Both insurers are saying that the other is the primary carrier.

Do you have any information that would help me convince my husband's carrier that it is primarily responsible for the claims?

Answer:

Your health plan should be able to describe how it coordinates benefits with other plans. Your benefits handbook should spell out the procedure for coordination of benefits (COB) — or determine if your plan simply doesn't have such a procedure.

COB is not a law; rather, it's a widely practiced industry standard. The "birthday rule" to which you refer typically applies only to coverage for children. For details about COB for children, read "Birthday rule" determines whose health plan covers your kids.

Coordination of benefits can be complicated, especially if you have one type of plan, such as an indemnity plan, and your spouse has an HMO. Here's how COB generally works when you and your spouse are covered under each other's plans:

First, the primary plan pays your claims if there is no secondary insurance. But, if there are multiple insurance policies for you and your spouse, the primary insurance policy would belong to the person whose birthday comes before their spouse's during the year. This isn't determined by age, but by the month and date of the birthday. If there is a second policy, it would pay for what the primary plan didn't, but only as long as the medical treatment or services are covered benefits under that plan. For example, if your visit to the doctor costs $60 and your primary plan pays $40 of that, your secondary plan would pay the remaining $20 (if the visit is covered).

The plans will not pay more than 100 percent of the cost of treatment, nor will they pay for treatment that isn't covered.

In determining which plan is primary and which is secondary, a plan without a COB provision is generally considered primary. When both plans have COB rules, the plan in which you are enrolled as an employee or as the main policyholder is primary. The plan in which you are enrolled as a dependent — on your husband's plan, for example — is secondary.

Your situation determines which of these provisions applies, but you can use these guidelines to help sort it out.

A final note: Dual coverage can be expensive, so be certain that it makes financial sense to pay for them both. You don't want to pay more than you'll ever get back in benefits by having dual coverage.

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Last updated: Dec. 7, 2009
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