It is not an unusual situation for a person to have coverage under more than one health insurance policy. For example, this often happens with spouses who have their own health insurance through their employers and are also covered through their spouses’ employers. Employees age 65 and older may have Medicare in addition to employer-sponsored health insurance. Retirees may have employer-sponsored retiree insurance, plus Medicare coverage.
Insurance companies will never pay more than 100% of the cost of your medical care. Nevertheless, you may save money by having more than one health insurance plan.
How Are Benefits Coordinated When You Have More Than One Health Insurance Policy?
When you are covered under more than one health plan, certain rules apply as to which plan pays for what. These coordination of benefits rules can vary somewhat among different states and providers, but the general idea is that one plan is primary and the other is secondary. When a claim is filed, the primary plan will pay what it is responsible for paying, as though the other plan did not exist. The secondary plan will then pay what it covers of whatever is left of the bill, up to 100%.
Which Health Insurance Plan Is Primary?
You don’t get to choose which plan is primary and which is secondary. That is determined under coordination of benefits rules. In most cases, your employer’s plan is primary. If you are also under your spouse’s health insurance plan, it is usually secondary. If you have a dependent child who is covered under your plan as well as your spouse’s, the birthday rule typically applies. This means the health plan of the parent whose birthday comes first in the calendar year is the primary plan.
What Happens If You Are Covered Under Medicare?
If you are 65 or older and covered under Medicare but still working, you may still have coverage under your employer’s plan. Whether Medicare or your employer’s plan is primary will depend on the size of the company. If it has 20 or more employees, the company plan is primary, and Medicare is secondary. If the company has fewer than 20 employees, Medicare is usually primary, with certain exceptions.
Coordination Of Medical & Dental Benefits
One drawback of having more than one health plan is that things can get complicated. This is particularly true if you have both medical and dental coverage and undergo a procedure, such as oral surgery, in which the lines between dental and medical coverage may not be clear. The language of both plans will determine if a particular service is covered under medical, dental, or both. If you or a family member is covered by more than one health insurance and dental plan in this situation, it can become even more complex. If you are not sure which health plan is primary, you can review your plan documents or speak with a member service representative. Our friendly agent can also help by reviewing your plan documents with you.