Can You Have Double Coverage Health Insurance?

It is possible and common to have multiple health insurance plans simultaneously, also known as dual coverage. Established rules determine how these plans interact, ensuring medical costs are covered appropriately without duplicating benefits.

Situations Resulting in Multiple Health Plans

Individuals often acquire multiple health plans due to various life circumstances rather than intentional planning. Married couples often have dual coverage when both spouses have employer-sponsored plans and elect family coverage. Each spouse’s plan covers them individually and as a dependent on the other’s plan.

Young adults under 26 can remain on a parent’s health insurance plan while also having their own employer-sponsored coverage. During career transitions, individuals may maintain COBRA coverage alongside a new employer’s or marketplace plan. COBRA allows temporary continuation of previous employer health insurance after job loss or reduced hours.

For those aged 65 or older, Medicare eligibility often coincides with active employer-sponsored group health plans, leading to dual coverage. Individuals who qualify for government assistance programs like Medicaid or CHIP may also have a private health plan, with Medicaid often supplementing private coverage.

Understanding Coordination of Benefits

When an individual has more than one health insurance plan, the concept of Coordination of Benefits (COB) determines which plan pays first and how to cover medical expenses without overpaying or duplicating benefits. This system establishes a “primary payer” and a “secondary payer.” The primary plan is responsible for processing the claim first and paying its share up to its coverage limits.

After the primary insurer pays its portion, the claim goes to the secondary insurer. The secondary plan may cover some or all of the remaining costs, such as deductibles, copayments, or coinsurance, depending on its terms and limits. However, the combined payments from both plans will generally not exceed 100% of the total medical service cost. Several common COB rules dictate the order of payment.

For dependent children covered by both parents’ plans, the “Birthday Rule” is frequently applied. This rule designates the plan of the parent whose birthday (month and day only) occurs earlier in the calendar year as the primary payer. If parents are divorced, the plan of the parent with custody often serves as the primary plan.

For those with Medicare and an employer-sponsored group health plan, the primary payer status depends on factors like the employer’s size; Medicare is typically secondary if the employer has 20 or more employees. Conversely, if the employer has fewer than 20 employees, Medicare usually pays first. Medicaid is generally always considered the secondary payer if other coverage exists.

Navigating Claims with Multiple Health Plans

When you have multiple health insurance plans, successfully navigating the claims process requires attention to specific procedural steps. The initial and important action is to inform your healthcare providers, including doctors and hospitals, about all your active insurance plans at the time of service. This notification helps ensure that claims are submitted to the correct payer in the proper sequence, which can prevent delays.

Typically, the healthcare provider will first submit the claim to your primary insurance carrier. Once the primary insurer processes the claim and determines its payment, they will issue an Explanation of Benefits (EOB) statement. This EOB details what the primary plan paid and any remaining balance. You or the provider will then need to submit this EOB, along with any necessary itemized bills, to your secondary insurance plan for consideration of the remaining balance.

It is prudent to track the status of your claims with both insurers to ensure they are being processed efficiently. Maintain copies of all submitted documents, including the primary EOB and any communication with the insurance companies. If questions or issues arise concerning payment, contact each insurance company directly to clarify their processing and payment decisions. While the secondary plan may cover a portion or all of the remaining costs, it is important to remember that it might not cover everything, depending on its specific benefits and the coordination of benefits rules.