Which health insurance policy should I use at this appointment?

March 24, 2015 7:05 PM

I have an appointment with a psychiatric nurse tomorrow, I have two insurance policies that overlap until the end of the month, and I don't know which policy would be the smartest to use.

I have Insurance A through healthcare.gov. It's a very high deductible plan ($6000) and I did not make a dent in it. I canceled it because I got Insurance B through a new job, but the cancellation is not effective until the end of the month.

I have not used Insurance B at all yet. It has a $1500 deductible. It's conceivable that I will meet it but not guaranteed since I don't have any chronic issues.

I'm seeing a psychiatric nurse who is in-network under Insurance A but not under B. So, I'm thinking that my out of pocket would be lower if I went through A, but I'd be putting more towards my deductible if I used Insurance B.

What is the smarter choice? I'm not planning to see her again after this because she's not in-network and I don't really like her anyway.

posted by fantoche to Work & Money (11 answers total)

It's not up to you; you don't get to decide among the two which is your primary coverage. One of those plans is your primary and the other is not; the plans know which is which or they will know over the next few months once they figure it out. It's a common misconception I see that people think they get to choose who will pay by billing their plans in the order they choose. Nope. My educated guess is, now that you have plan B, they are your primary because having employer insurance makes you ineligible for subsidized exchange coverage. I would suggest calling Plan B to explain the situation and see what they say. Even without a straight answer from them, I would probably still provide the office with Plan B as the primary.
posted by ThePinkSuperhero at 7:24 PM on March 24, 2015 [6 favorites]

Give them both. They will sort it out.
posted by J. Wilson at 7:39 PM on March 24, 2015

The answer is going to depend on when Insurance B is effective (not when Insurance A is effectively cancelled). You can call Insurance B to find this out. If the policies' effective dates overlap, the terms of the policies will govern, and frankly you're best off simply providing your provider with information for both and letting them fight it out rather than trying to game it. I am an employee benefits attorney, but IANYEBA.
posted by mchorn at 7:41 PM on March 24, 2015

If you wish to get a head start on the process, try searching for "coordination of benefits" forms on each insurer's website. You'll probably be asked to fill those out at a later date if you don't do it now. Both insurances should be billed unless the primary pays @ 100%.
posted by txtwinkletoes at 8:00 PM on March 24, 2015

Way back in the day when I had coverage under two policies (my work and spouse's work), the doctor's office submitted the claim to the primary coverage (my work policy) and they applied their in-network deductible, calculated how much they would pay and I should have to pay and then sent me the EOB. I then sent the EOB to the second coverage who calculated how much they would pay, adjusted for what the other plan paid (so I didn't get more than 100% of the total) and then they paid the rest.

So based on that experience:
- I think regardless of the order, if you make sure that it gets submitted to A, then the office should give you in in-network discount when it gets processed (first OR second).
- be prepared to manually send in the claim form with the first EOB to get it processed by the second insurance company.
- it may save you time and aggravation to call and ask who should be primary. I would probably call B first just because they might possibly have better customer service.
posted by metahawk at 10:29 PM on March 24, 2015

If Plan-B is in-effect on the day your see the nurse, that is the policy you should use. As far as the administrators of Plan-A are concerned, the day Plan-B came into effect, it became your primary (or only) insurance.
posted by Thorzdad at 5:39 AM on March 25, 2015

Response by poster: Why would either policy pay anything, given that I haven't met my deductible?

My thinking that since she is in Insurance A's network, they have negotiated a lower rate. Let's say $100 for an office visit. I would have to pay all of that. That would be applied to my $6000 deductible, but that's irrelevant because that policy is ending.

She is not in Insurance B's network, therefore it would be a higher rate, let's say $200. I would have to pay all of that. But all of that $200 would be applied to my $1500 deductible. This is my dilemma.

How would submitting claims to both companies change any of this? From past experience, if this insurance bullshit takes longer than 30 days my doctor's office will just send my bill to collections.
posted by fantoche at 5:56 AM on March 25, 2015

I agree, I don't think either plan will pay anything, and maybe they won't care about straightening out the COB afterwards given that fact. If it does get caught up immediately, though, it could go out to collections. You should be able to call each plan for details on the allowed amount for your visit. Also, for insurance B, check that the $1500 deductible includes out-of-network stuff; it seems like most plans have separate in- and out-of-network deductibles. I still think that Plan A is probably no longer valid now that you have employer coverage.
posted by ThePinkSuperhero at 6:09 AM on March 25, 2015

Response by poster: But how would Plan A - or the doctor's office - know that I have employer coverage unless I tell them? Plan A's website estimates my cost at $100 because she's in-network. Plan B's website doesn't tell me anything about out of network allowable costs (you were right that the deductible is different, it's $4000 for out-of-network).
posted by fantoche at 7:26 AM on March 25, 2015

They have their ways, believe me (even our eligibility software here at the office can tell us if a patient has or had additional coverage, and it'll flag it if there's a coordination of benefits issue; I imagine their systems are similar or better). The plans work hard to know who they have and do not have to cover because it affects their bottom line. And they will go back months (or years!) later, reprocess claims and take back payments if it turns out they were not primary at the time of the appointment. Will they do that, though, if they didn't pay anything and it's only an issue of deductible application? Maybe not.
posted by ThePinkSuperhero at 8:16 AM on March 25, 2015 [1 favorite]

For a psychiatric office visit you may just have a copay of $10 or $25 or $30, especially one that's in-network.

You can always call your Plan B insurance and ask them.
posted by amaire at 1:06 PM on March 25, 2015