Covered by both my insurance and my husband's?

December 29, 2015 2:24 AM

I'm a dependent on my husband's health care (Blue Cross). I'm also covered at work (Kaiser). Should I cancel my work coverage to avoid paperwork nightmares?

We expect a lot of health costs this year (I'm having a baby), so it makes sense for me to switch to his network, because the family co-pay on his is lower than the individual co-pays on our plans added together.

My understanding is that if I have insurance, his company is going to try to bill mine first, before covering me as a dependent. And Kaiser will say "using an out of network provider is 'not covered,' so we won't pay," and then his will have to evaluate whether they would pay, right? It's not likely that a provider would take both his insurance and mine, given Kaiser's HMO model.

Someone suggested I ought to just cancel my own insurance coverage to keep things simple. But with the baby coming, I'm tempted to keep my coverage as a backup -- I understand it; I have an ob-gyn (albeit not one I'm in love with); the therapist I see very sporadically is on it; maybe they'll cover some post-birth physical therapy that his won't...

But how will billing happen? I don't want to end up spending hours being bounced between two massive bureaucracies for every cost we incur. I don't want to have to somehow front $12k for a labor and delivery charge until the responsible party gets sorted out, or have an unpaid hospital bill screw up my credit.

Does anyone have experience or guidance here? Thank you!

posted by slidell to Work & Money (19 answers total)

Having double coverage in your situation will be a buerocratic nightmare- your plans will fight amongst themselves for quite some time over every single claim. It's highly unlikely the secondary policy will cover so much the first doesn't to make it worth the hassle. Cancel one, for sure.
posted by ThePinkSuperhero at 3:25 AM on December 29, 2015 [3 favorites]

Your insurance plan will be primary and your spouses plan will be secondary. Secondary insurances will not cover copay amounts to the primary insurance. I am not sure how the out of network issues will be handled, but if you are unable to find providers that take both it may be best to just settle on one plan and only use it.
posted by Apoch at 3:37 AM on December 29, 2015 [3 favorites]

It may be worth checking with hr to see if there is a buyout/waiver option. We were able to cover the slightly increased costs of my spouses much better health care by declining insurance from my employer who will then pay me a minimal amount back for opting out (public sector only perk, perhaps?)
posted by Exceptional_Hubris at 3:59 AM on December 29, 2015 [1 favorite]

You need to check the terms of your plans. In some cases if you are covered under your employer your spouse's plan will not cover you. You'll have to ask a few folks because this is tricky business and not everyone understands.

Kaiser is very different from Blue Cross. With Kaiser you go to their facility and you use their physicians. It used to be that only Kaiser patients could use Kaiser resources. So if you're in an OB practice at Kaiser, chances are that you'd have to change to a new doctor and a new facility if you cancelled them.
posted by Ruthless Bunny at 4:00 AM on December 29, 2015

Please keep in mind that, if you participate in your plan through a cafeteria plan (pre-tax salary reduction), you actually can't just cancel mid-year without an IRS-sanctioned reason. If it is a January 1 plan year and this is open enrollment (not likely - they are typically Oct-early Dec), you could do it, but otherwise you would have to have a status change or life event that would allow you to drop your coverage (and that status change usually requires that your eligibility for your plan or your spouse's plan - e.g. when you get married and gain eligibility - or when there is a significant increase or decrease in cost of one of the plans).
posted by Pax at 4:27 AM on December 29, 2015 [3 favorites]

My previous employer had a provision that stated if my spouse was eligible for her own coverage she had to take it and was not eligible to be covered under my insurance. So I'd talk to both HR departments, and document everything carefully, before doing anything.
posted by COD at 4:49 AM on December 29, 2015 [4 favorites]

I ended up having a high risk pregnancy and having two insurances was really helpful because sometimes one or the other wouldn't cover super expensive test. I spent 50 hours on the phone sorting that crap out but it saved me 20k.
posted by Kalmya at 5:14 AM on December 29, 2015 [2 favorites]

Response by poster: Wow, okay, I'm more freaked out than ever, but this is good information. Thank you all.

I'm not sure my clarifications will "clarify" anything, but here are a few details. We both asked our HR people and his did not raise concerns like "if her employer offers coverage, she can't be covered by us." We should document that, apparently.

Our open enrollment periods did not align, such that it was not possible to get info on his insurance coverage and co-pays, so I wasn't comfortable just declining mine, but I might've tried harder if I'd realized that canceling later wasn't going to be possible. (It's really not possible to cancel after open enrollment ends?)
posted by slidell at 5:21 AM on December 29, 2015

I believe having a baby is an event that would allow you to change insurance.

Before my divorce, my company gave me a small amount in payroll (about $50 a month) for being covered on my ex-husband's insurance.
posted by hrj at 6:17 AM on December 29, 2015 [1 favorite]

In Canada, it's clearly laid out which private insurance company pays first (with elaborate tiebreaker formulas and everything). Do you have a local insurance council you can contact to ask them how a billing situation would be resolved in your case? It should be as simple as "claim is submitted to primary first, and then to secondary, every time". If you keep both coverages, always submit the claim to both companies, even if the first pays above the level the second would. There may be a deductible on the secondary coverage that gets reduced even if not used, putting you in a better position later in the year.
posted by GhostintheMachine at 6:40 AM on December 29, 2015

I agree that it's possible that the COB provisions of each plan might address this situation, but my experience is that not all plans are helpfully drafted. And then the application of the rules might still be confusing.

I believe having a baby is an event that would allow you to change insurance.

Birth of a child would allow the baby to enroll and a spouse to enroll in a plan if not already enrolled (HIPAA special enrollment), but - and it's possible that I'm reading this too conservatively - if an individual is already enrolled in both plans, I don't think that having a baby would meet the consistency rule in IRC 1.125-4(3) because the individual who is enrolled in both plan isn't having a change in eligibility for either plan as a result of birth. The baby can be enrolled in any coverage option for either employer and both spouses can switch to that option under that plan (again, special enrollment requirement under HIPAA), and if the individual were enrolled only in her own plan, she could drop that plan and enroll in the spouse's plan (if the plan itself is written to allow it), but I don't think cafeteria plan rules would be met in the case of current double-enrollment (plus the plan doesn't have to allow any cafeteria plan election changes other than associated with HIPAA special enrollment).

1.125-4
(3) Consistency rule
(i) Application to accident or health coverage and group-term life insurance. An election change satisfies the requirements of this paragraph (c)(3) with respect to accident or health coverage or group-term life insurance only if the election change is on account of and corresponds with a change in status that affects eligibility for coverage under an employer's plan. A change in status that affects eligibility under an employer's plan includes a change in status that results in an increase or decrease in the number of an employee's family members or dependents who may benefit from coverage under the plan.
posted by Pax at 7:11 AM on December 29, 2015 [1 favorite]

I have had two insurances but it's been a long time. My sick parents have always had two insurances by adding each other to work plans.
What happens is one gets assigned as primary and pays as if you only have that one.
Whatever amounts are left over are sent to the other company to see if they will pay any of what the primary didn't pay.

My insurances never fought. It was a dream come true. I never paid a dime for anything.
My dad has a chronic condition and it's great when insurance #2 picks up what #1 didn't pay in his hospital stays. As far as I know they have never had a billing mess either.
Keep both!
posted by littlewater at 7:29 AM on December 29, 2015

One thing that makes your situation different from many is that Kaiser is an HMO with in-network coverage only and any Kaiser facility would be out of network for the BCBS plan.

That means that if you are planning on having the baby in a in-network facility for BCBS then Kaiser wouldn't cover anything anyway so you wouldn't really run into the exhaustive paperwork nightmare that most people run into in these situations. When BCBS asks for the Explanation of Benefits from Kaiser they will see 0% covered so it will all get processed through BCBS anyway.
posted by magnetsphere at 7:44 AM on December 29, 2015 [1 favorite]

I had two insurances for a few years - my primary student Aetna policy, and a secondary United through my domestic partner. Initially there was a little bit of hassle that required a couple of phone calls to figure out, but otherwise it was great in that things that were not covered by the primary were often picked up by the secondary. As a result, I almost never paid anything out of pocket, other than, you know, the premiums. In my case, the secondary DID cover the co-pays of the primary.

You are dealing with different companies and policies, so YMMV. The Kaiser/out-of-network issue sounds like it may make dual coverage a non-starter - I haven't dealt with them. But if it would potentially work out, I would take a good look at the two policies and see if there are substantial differences in coverage (e.g., does one cover bloodwork well while the other requires a lot of co-pays?). Then consider whether paying the additional premium for the second policy is potentially worth that difference in coverage.
posted by scrambles at 9:07 AM on December 29, 2015

I had double coverage for exactly one month when I was pregnant with my last child. Both coverages were even with the same insurance company. Three years later I got sent to collections for a $40 bill that everyone seemed to agree I didn't owe (I certainly didn't owe it). It was a complete nightmare. The nightmare started because the dr insisted that they had to bill my insurance first, since it is automatically "primary". So you can't just say "use this one first." If you want to use your husband's first, you need to cancel yours. If you think you'll come out better using both, call the secondary insurance and ask to speak to someone about coordination of benefits and see what they will cover after yours is done paying.

Overall, this is a good problem to have, though.
posted by dpx.mfx at 9:58 AM on December 29, 2015

The nightmare started because the dr insisted that they had to bill my insurance first, since it is automatically "primary". So you can't just say "use this one first."

Very important point worth repeating for everyone- the order of how your medical coverage is used (which plan is primary and which is secondary) is fixed; you don't get to decide who processes and pays first.
posted by ThePinkSuperhero at 10:32 AM on December 29, 2015 [1 favorite]

One thing I don't see mentioned: Obamacare no longer requires spousal coverage. It requires that companies cover dependent children up to age 26, but it does not require that the company cover the spouse. However, if you cancelled your coverage and got coverage under his plan and then they changed their policy and no longer covered you, loss of coverage would be a "qualifying event" to get coverage at your place of work, even outside of open enrollment.

Since your companies have different periods of open enrollment, you should talk to HR at both places and find out if you can get family coverage at his open enrollment and if this new coverage will count as a qualifying event for dropping your coverage. Though, honestly, I was not aware or needing a 'qualifying event' to cancel coverage (and I worked in insurance for a few years, though not major medical). My understanding is that you need a qualifying even to get new coverage outside of open enrollment, not to cancel coverage. So talk to HR at both companies. You may be able to cancel at will if you get new coverage you prefer to your current coverage.

My understanding is that if I have insurance, his company is going to try to bill mine first, before covering me as a dependent.

This is not how coinsurance works. How coinsurance works is that the healthcare provider bills the primary insurance first. In your case, the primary will be your coverage from your job. If the secondary insurance is better or covers something the primary does not, then they are billed next.
posted by Michele in California at 5:33 PM on December 29, 2015 [1 favorite]

Obamacare no longer requires spousal coverage. It requires that companies cover dependent children up to age 26, but it does not require that the company cover the spouse.


No federal law ever required spousal coverage (though it's possible some state or loca law might or might have). Part of the ACA "requires" employers to cover dependent children (it's a "pay or play," employers aren't violating federal law if they don't, they just pay a penalty, and it's a perfectly legitimate business decision in the eyes of the law). Another part of the ACA requires employers that have decided to cover dependent children to cover them up to age 26. That requirement means that if an employer chooses to cover depend dent children and violates the age 26 limiting age (including conditioning coverage on being unmarried or a student), they are violating the law ($100 per day per violation).

As to canceling coverage, insurance companies will often tell folks and employers that they can cancel at will, but that's not usually true for employer-sponsored coverage. It's not insurance rules or laws that prevent at-will changes (although an insurance company's own rules won't usually allow at-will ENROLLMENT), it's cafeteria plan rules, which are federal tax code provisions that allow employers to allow employees to pay for coverage (through insurance or self-funded coverage, major medical or any other benefit that is offered through this mechanism) through a pre-tax salary reduction.

I had a colleague that explained dropping coverage without a cafeteria plan status change thusly, tongue firmly in cheek: you can drop coverage, but you will still have the salary reduction in the amount of the cost.
posted by Pax at 3:19 AM on December 30, 2015

Response by poster: Thanks, everyone. I've been persuaded to cancel my insurance and confirmed that being officially added to my husband's insurance is an adequate event to make that possible. (No, they won't give me a salary boost in exchange for these lower costs, but they never would have, even if I'd declined during open enrollment.) I still wish I could wait to cancel until the 1st appointment on his insurance goes well and gets paid, but I suppose life is full of risks.
posted by slidell at 2:36 PM on December 30, 2015 [1 favorite]