What Happens If You Have 2 Vision Insurance Plans?

Having two vision insurance plans can offer enhanced coverage for eye care services and products. Understanding how these plans work together allows individuals to maximize their benefits and manage out-of-pocket expenses. This involves comprehending the rules that govern how multiple insurance policies coordinate payments.

Understanding Coordination of Benefits

Coordination of Benefits (COB) is a standard practice designed to prevent individuals from receiving duplicate payments for the same vision care services when covered by more than one insurance plan. COB ensures that the total benefits paid by all plans do not exceed the actual cost of services received, fairly distributing financial responsibility among the different insurers.

Under COB, one vision plan is designated as the “primary” plan, which pays for services first. The other is considered the “secondary” plan. The primary plan processes the claim as if it were the only coverage available. After the primary plan has paid its portion, the secondary plan may then contribute towards any remaining eligible costs, up to its own benefit limits.

The secondary plan helps cover expenses like co-pays, deductibles, or any unpaid portion of a bill that the primary plan did not fully address. This system prevents overpayment while allowing patients to utilize their benefits.

Determining Primary and Secondary Plans

Identifying which vision insurance plan is primary and which is secondary typically follows established rules, though specific plan documents should always be consulted. Generally, the plan that covers an individual as an employee is considered primary over a plan where they are covered as a dependent. For instance, if you have coverage through your own employer and are also on your spouse’s plan, your employer’s plan is usually primary.

For dependent children covered by both parents’ plans, the “Birthday Rule” commonly applies. Under this rule, the plan of the parent whose birthday falls earlier in the calendar year (month and day, not year) is usually primary.

If parents are separated or divorced, the plan of the custodial parent is generally primary, unless a court order specifies otherwise. It is always advisable to contact your plan administrators or human resources department to confirm the specific rules applicable to your situation.

The Process of Using Both Plans

When utilizing two vision insurance plans, the process generally begins at the vision care provider’s office. It is important to inform the provider’s staff about both your primary and secondary vision insurance plans before receiving services. Providing all relevant insurance information upfront allows the provider to properly manage the claim submission process.

The provider’s office will typically submit the claim to your primary vision plan first. Once the primary plan processes the claim and pays its allowable portion, an Explanation of Benefits (EOB) will be generated, detailing what the primary plan covered and any remaining balance. This EOB is a crucial document for the next step.

After the primary plan has paid, the provider’s office will then submit the remaining balance to your secondary vision plan, along with the EOB from the primary plan. The secondary plan will review the claim and pay any eligible remaining costs, up to its own benefit limits and according to its coverage terms. Any costs not covered by either plan remain the patient’s responsibility.

Important Considerations for Dual Coverage

While having dual vision coverage can significantly reduce out-of-pocket costs, it does not guarantee complete coverage for all expenses. Deductibles and co-pays may still apply to each plan. For example, you might need to meet a deductible with your primary plan before its benefits activate, and your secondary plan might have its own co-pays for certain services.

Each vision plan typically has annual maximums for benefits. The secondary plan will not pay beyond its own maximum, regardless of what the primary plan has paid.

Plans may also have waiting periods for certain benefits. This means you might need to be enrolled for a specific duration, such as six months or a year, before full coverage for services like frames or lenses begins.

Frequency limits often apply, dictating how often you can receive a new eye exam, frames, or contact lenses under each plan. For instance, one plan might cover new frames every 12 months, while another covers them every 24 months. Covered services can also differ between plans; one plan might cover contact lenses, while another might only cover eyeglasses.