Connecticut State Office of the Healthcare Advocate. For Employers Coordination of Benefits. How it Works First, the primary plan pays your claims as if there were no other insurance.
In determining which plan is primary and which is secondary, a plan without a COB provision is generally considered primary. When both 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--your spouse's plan--would be secondary. In addition, if you have COBRA coverage as well as coverage with another plan in which you are enrolled through an employer, your COBRA plan is secondary and your employer's plan is primary.
That includes the provider. If the doctor isn't part of the secondary plan's netowrk, the plan may not cover their portion. That's why it's vital to make sure you go to providers in both plans' networks.
Remember, the "birthday rule" and its exceptions aren't insurance laws. Rather, they're common claims practice -- and not all plans follow these customs. You should read your policy or membership agreement to see what procedure your health insurer has in place. If you're still uncertain, contact your plan's customer service department.
And make sure you know the payment procedure before you or your children visit the doctor or you may find yourself personally responsible for some unexpected medical bills.
See Insure. However, this stipulation only applies if a group plan covers both parents. If you have COBRA and an employer-sponsored group health plan covers your current or former spouse, he or she provides primary coverage.
The health insurance birthday rule allows you to maximize benefits for your dependent s. For instance, the secondary plan may be used to cover the amount left unpaid by the primary plan. Knowing what will be covered — and how much of it — will help you avoid potential coverage gaps that could lead to unforeseen health care expenses.
Not all plans follow the birthday rule. This means it's essential that you read your health insurance policies carefully and work with your insurance companies to understand how the insurer coordinates benefits. It's a good idea to determine which plan is the primary and which is the secondary before you start incurring medical costs. The health insurance birthday rule is a great way to ensure that your child has full coverage in case of an emergency, but it can also be really tricky.
And that can be very distressful, especially when you start to get medical bills, it isn't always easy on any household budget. The birthday rule might seem like a hassle in the beginning but it is helpful in preventing overpayment. Instead of accidentally sending an insurance bill to a primary or secondary insurer and paying for care twice, this simple system helps keep things organized.
No insurance company would like to pay a policyholder twice for the same service, so using the birthday rule for medical insurance they identify which insurance plan should be paying and then they work accordingly.
There are some ways to avoid the birthday rule for insurance coverage. One way would be by taking a close look at your insurance and comparing it with what your partner's health insurance plan. Find out which one of the health plans provides more benefits than the other. If your plan makes more sense and offer better coverage, add your partner to your plan and drop another one.
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