Health Insurance - Dual Coverage
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Health Net and Kaiser Bills - Coordination IssuesOct 2010
BACKGROUND: Child is covered under UC Health Net by Mom (me) Child is covered under Kaiser by Dad. Been using Health Net (with Alta Bates) for child's major medical insurance to use Children's Hospital for the surgery which has been taken place already, plus used Children's Hospital even before that, so had referrals and approvals from Alta Bates.
PROBLEM: It's come to light that a child covered by more than one plan has the PRIMARY PLAN of the parent whose birthday is earilier in the year. In this case, this means Kaiser is the Primary Plan, not Health Net so we should have been using Kaiser, not Health Net.
I think Alta Bates/Health Net AND Kaiser will both reject the bill from Children's Hospital. Children's now knows we also have Kaiser insurance so we can't use them anymore. Alta Bates is being billed first, will find out the PRIMARY insurance is Kaiser and pass the bill to Kaiser. When Kaiser gets the bill, since we've been using Alta Bates/Health Net, Kaiser will say they did not pre-approve this and reject it, too!
Children's told us of the possible rejected Alta Bates bill the day our child was discharged from surgery. Yet we already had the authorization from Alta Bates. (but of course there is the fine print which will allow Alta Bates to reject the bill.) There is a lot more I can add but want to make this short.
QUESTION: Can anyone recommend a lawyer for this? Has anyone ever been in this situation? What did you do? Please let me know your experience with working with a lawyer/legal so I have some idea of what to expect. I think we will probably have to consult with a lawyer. Any additional info you can give would be welcomed.
Hi- We went through this but it was Aetna and Healthnet, if I remember correctly. Also something similar when it came to braces as well through my UC dental plan and my husband's differing plan.
I don't have any advice when it comes to legal issues. But each time, it was explained very straightforward and it was even explained at open enrollment. So, I am not suggesting you did anything wrong, but you may want to check it wasn't in the fine print anywhere. It is pretty common to assign primary coverage the why you described. If the surgery is beyond what you can afford and the insurance companies won't listen to your pleas, inquire about ''charity care.'' They can write off a certain percentage of the bill. It won't be easy to get approved but it may help. Not a doctor
It's also worth a shot calling your senator's office. The healthcare plan is changing so rapidly these days. Give them a call, explain your situation, ask if there's anything in the new plan that might help you. No guarantees but it can't hurt to ask. Ann
Are you a UC employee? UC has a few benefits employees whose sole job is to help covered employees deal with problems like this that arise with health plans. They are tireless in these efforts and are strong advocates. It still takes a while, but this is the route to go if one of the plans is through UC. In any case, my experience when having dual coverage for kids was that anything not covered at all by one plan had to be covered by the other (if it were a covered service), so in your case, if Kaiser says no (after the fact, since they did not authorize it) and Health Net already approved it, then it seems Health Net should be the one to pay. (This is different from a service that was partially covered by the first plan; there it depended on the type of insurance agreement, whether benefits could be combined from 2 plans or not--UC allows this, my husband's plan did not, but as UC was their secondary coverage, the kids got both plans). Makes one believe in Single Payer, doesn't it.
My family is currently covered by Blue Cross PPO through my husband's work. This is our only health insurance right now. However, premiums are going up for both us and the portion that the company pays, AND more of our providers are dropping Blue Cross. So essentially, we are paying more for less coverage.
I have two options for a second health insurance program: one would be an out-of-state provier through a company I do some work for; the other would be coverage through a professional society and may be a different carrier completely, like Kaiser or Health Net.
Does it help to have a second insurance provider? Or would we be constantly chasing two companies to get them to pay anything at all? How would we determine which carrier is primary and which is secondary for our kids? What is the best way through this maze? Trying to Keep Healthy
Hi--your question about health insurance is a timely one, especcially as premiums go up and people are looking for solutions to the higher costs. The problem with two insurances is that THE INSURERS will argue about which is primary and which is secondary, and that can lead to claim dealys and bills from the providers because of the delays. Best to find the one most effective coverage that you can afford. Joanna
Your primary will be the provider attached to your job. Your husband's primary will be the provider attached to his job. Your kids' primary (quite arbitrarily) depends on who was born first btw you and your husband. The first born between the two of you's primary provider will also be your kids' primary.
Coordinating insurance is a big pain in the butt. The primary will usually pay without much hassle provided you get the doctor's office clear on the procedure. It's the secondary that's the problem. Your service provider needs to send the Explanation of Benefits (EOB) describing the primary carrrier's action to the secondary along with the claim to the secondary to get them to do anything. Getting the service provider to do this correctly depends on the office claims processor's laziness and intelligence levels. Labs (such as Quest) will try to bill you directly over and over and will generally belligerently and rudely refuse to bill the secondary at all leaving you to the task of collecting from them yourself. This is, of course, difficult for you to do because you don't have the special claim codes that all the procedures would be billed under and the secondary will generally be very slow to respond without periodic harrassment from you over the phone. In theory, the secondary will review the claim and cover whatever portion they would normally cover once the primary adjustments have been applied.
However, once you meet the deductible of the primary, they have to pay everything for in-network services and then you're mostly home free and the secondary would only need to be involved when the services are out of the primary's network. So it could be worth being double covered anyway depending on how stable your jobs are, what the deductibles are, and what the costs per month would be.
My personal experience is that I do spend some time working with the service providers to bill correctly, and the secondary to pay. My primary is UnitedHealthCare ($2000 deductible! Argh!) and secondary is Blue Shield PPO -Double Covered
Does anyone out there have dual coverage with healthnet and Kaiser. I have Kaiser as my primary insurance, and Healthnet as my secondary insurance (by HMO birthday rule). I just called a practice that will accept Healthnet, but won't accept me if I am dual covered with Kaiser, b/c they say that Healthnet gives them a hard time with payments. They want me to pay out of pocket and get reimbursed. I called both Kaiser and Healthnet, and the insurances both reassured me that there should be no problem getting my bills reimbursed by Healthnet, if I see a Healthnet plan physician, but I'm concerned. Has anyone had experience with this dual coverage situation? Good or bad? Anon
Hello - I worked in a hospital business office for many many years and my primary task was checking on patient's insurance coverage. However, please temper my response with the fact that I have been out of the field for almost 5 years. With double coverage, there are a few things to consider.
1. If your secondary coverage is with an HMO or EPO or some other types of restrictive plans like that, they may not pick up the balance after the primary ins pays unless the service was rendered using a provider that is also in the 2nd ins's network. You may also need to follow all the rules of your 2nd ins. This is often impossible: if your prime ins is, say Health Net and your 2nd is Kaiser, well Ksr will not cover *any* non-emergency care at a non-Kaiser facility.
2. The second ins may not pay if the prime ins paid an amount equal to or greater than the 2nd ins *would* have paid had it been prime. (Confusing?). If the normal benefit for prime ins is 90% and the normal benefit for 2nd ins is 80%, 2nd ins may not pay anything since the prime paid more than its (i.e., the 2nd ins's) normal benefit.
3. Similarly, using the above %-ages, if the prime paid 90%, the 2nd may only pay 80% of the balance due after the prime pays.
4. There are other issues, such as pharmacy formularies, etc., you may need to investigate. My advice: read the contracts carefully *before* you rack up bills that you expect the 2nd ins to pay. Good luck! michael s.
We have dual insurance, mostly so that we can have both an HMO (good for routine care) and a PPO (good if you need a specialist). We don't pay much for this, though (~$100 a month for both).
We decided we were very glad to have it quite recently, when it looked like we were going to have to go to a UCSF biliatory duct surgeon for care, and he wasn't covered by the HMO.
If it's a choice between two HMO's I don't think I'd bother, I'd figure out which one works best for you and choose that. If it's between two PPO's and you have a percentage you pay, coordinated care will benefit you in that you will pay less for both. We've run into this with dental insurance...A root canal was paid at 50% by both insurance companies, thus 100% for us. Myriam
I am fortunate enough to work for a firm that provides health insurance to my entire family at no cost to me. We have found it worthwhile to also pay the relatively small employee contribution to cover me and our son on my husband's insurance. The double coverage means we pay almost nothing out of pocket for health care provided. I had several cavities filled a few years back and paid zero -- my policy covered 80% and my husband's picked up the other 20%.
Whether this is worth it to you depends on how much it costs you, what is covered and to what extent (and whether your doctors accept both policies), and how much care you expect to need in the coming year. Has it been a while since you've been to the dentist? Are you planning a pregnancy? Does anyone in the family have a chronic condition requiring regular or recurring care (asthma, diabetes, depression)? Try to estimate the amount you'd end up paying out of pocket in a year, and compare that amount to the premium you'd pay for the second policy. If it's more, you come out ahead with the additional coverage, of course, and even if it's about the same, the second policy is a good idea because (1) the premium contribution is pretax dollars, and (2) it'll cover the unexpected -- you won't be facing that $1500 maximum deductible in the event of an emergency hospital admission.
It's not that likely that your new employer would agree to put the money they would have spent on your health insurance toward some other benefit, although you can certainly try. You've got a better chance if it's a small company or there is already some form of ''cafeteria'' benefit plan in place. (Congratulations on the new job!) Holly