Why is my American dental insurance insisting I'm not covered?

September 13, 2021 5:18 AM

Am hoping to gain some insight about an insurance problem I'm having in the United States, where the main provider says I'm covered, but the secondary agent/supplier (not sure of current term) insists that I'm not. Details inside.

So I was laid off from my job in the United States in May. I elected to continue the vision and dental coverage under the COBRA option, which means I pay the full premium every month for coverage of myself and spouse. Keep in mind this is the same insurance we've had for years, with no issue.

Wife goes to dentist for a procedure and the office calls a few weeks later saying we're not covered. I call and check with the company, PlanSource, and they say yes, my wife and I are absolutely covered.

However, the our dental insurance card says has a company name of Ameritas on it and after calling them, they say no, our coverage has been canceled. I talk to Plansource again and they say yes, we're covered and that Ameritas is some third party type agent for them, not sure of exact term and it's not really, but no matter, PlanSources says should absolutely be covered. I talk to Ameritas again and they have no clue about PlanSource and who they are, so they insist we're not covered.

Can anyone offer any insight as to what's going on here? I can literally call or go online to Plansource and they say I'm covered, they accept the payment premiums. But Ameritas says no and I can't get a really straight answer on how these two companies are related and say different things.

posted by clocksock to Health & Fitness (15 answers total)

I can’t tell you what’s going on, except that it sounds like the term you’re looking for is third party administrator (it sounds weird that Ameritas would have no idea who they are but it’s happened to me.) If PlanSource will talk to you, would they maybe call Ameritas to sort this out?
posted by jameaterblues at 6:11 AM on September 13, 2021

What absolute fuckery. Every state has an Insurance Commission (name may vary). Go to your state's Attorney General's website, call any consumer protection line, and find the insurance regulatory agency/ Insurance Commission, call them, too.
posted by theora55 at 6:19 AM on September 13, 2021

Have you talked to the benefits administrator at your former employer? Ask them for help, and get written proof that your COBRA payments were allocated correctly.
posted by dywypi at 7:02 AM on September 13, 2021 [4 favorites]

OK, based on googling the names, it seems like Ameritas is probably the one actually providing the insurance and PlanSource is your benefits administrator? I think you probably need to stay on the phone with both PlanSource and Ameritas until this is hashed out. If your former employer has HR/benefits people, get them involved as well.
posted by mskyle at 7:08 AM on September 13, 2021

Response by poster: What does " it seems like Ameritas is probably the one actually providing the insurance and PlanSource is your benefits administrator? " mean in practical terms. I'm giving PlanSource money for insurance, the full premium, shouldn't they be covering me?
posted by clocksock at 7:13 AM on September 13, 2021

PlanSource is a middleman, so your company only had to contract with one company for all their insurance and other benefits, instead of negotiating with individual insurance companies separately. My company uses Trinet which is basically the same deal; they're not the actual insurers even though your payment goes through them.

(Ain't the American health care system grand?)
posted by ook at 7:29 AM on September 13, 2021

PlanSource is not an insurance company. It is a benefits-administration provider. In this instance, PlanSource is the go-between that connects you, the insured, to Ameritas, the insurer. This is the job that is often done by the benefits coordinator in a company, who is a member of the HR staff. Unfortunately it is the insurer, not the benefits coordinator, who makes the call as to what is and is not covered. Think of it like someone in HR saying that a thing is covered but the insurance company saying it isn’t. Since there is a disagreement here, I would suggest you see if you can get on a conference call with reps from both PlanSource and Ameritas so they can directly communicate with one another in your presence.
posted by slkinsey at 7:30 AM on September 13, 2021

Response by poster: PlanSournce is happy to take my money, but have no actual control over whether I'm insured, is that correct? Ameritas isn't collecting money from me and since being laid and choosing the Cobra option, they...terminated my coverage because they weren't getting the money? Is that's what's going on?
posted by clocksock at 7:42 AM on September 13, 2021

Ugh, this is a hassle. I'd try contacting HR at your old job, they probably have the most standing to correct this. It sounds like your actual insurer may not have gotten the memo that you elected COBRA so they cancelled your coverage. Don't panic though - in my experience this type of issue can almost always be corrected retroactively, so you get it sorted out then your wife's dentist can resubmit the claim.
posted by zibra at 8:08 AM on September 13, 2021

Could they be submitting the claim to the wrong place? Are they submitting it directly to Ameritas or the third party administrator, PlanSource? I used to have issues where my doctor’s office would submit claims directly to Aetna instead of the third party administrator for the insurance. They would always get a message back from Aetna that I wasn’t covered by them. I would always have to tell the doctor’s office to submit it to the third party administrator. Does your dental card say where to submit claims?
posted by hazel79 at 9:23 AM on September 13, 2021 [1 favorite]

PlanSournce is happy to take my money, but have no actual control over whether I'm insured, is that correct?

As I understand these things to work, PlanSource takes your premium payment and passes it along to Ameritas. I'm unsure how PlanSource makes money in this arrangement, but I imagine they are directly paid by the employer for the service and/or take a cut of the payments. The value to the employer is that PlanSource takes over quite a bit of the administrative and other functionalities that would otherwise be done by HR personnel. What's important in this case is that PlanSource's word on what is and isn't covered is effectively the same as the word of benefits administrator in an HR department -- which is to say hopefully well informed but not definitive. If there is a misunderstanding, miscommunication or mistake there, the way to solve it is to get everyone on the horn together, if possible. At least then PlanSource and Ameritas can discuss why one thinks its covered and the other isn't. PlanSource has a vested interest in giving accurate information and advice. If you can make the argument that you only got the procedure because you relied on PlanSource's claim that it was covered, all the better. Maybe PlanSource will make you whole. If this is a procedure that previously has been covered for you and is now claimed not to be covered, that suggests that this may be a miscommunication or incorrect filing situation.
posted by slkinsey at 9:41 AM on September 13, 2021

Ah! Upon reading more carefully, I see that Ameritas thinks your policy has been cancelled. This is absolutely a situation in which you need to force PlanSource and Ameritas to get on the phone with one another until Ameritas restores your policy. This should be high priority for PlanSource.
posted by slkinsey at 9:44 AM on September 13, 2021 [2 favorites]

I think you need to call PlanSource and tell them that there is a problem with your coverage with Ameritas and that they need to contact Ameritas and get it fixed. Offer to stay on the line while the PlanSource agent reaches to Ameritas. It may take a few calls for people to research and fix the problem but the solution will require PlanSource to work with Ameritas - your job is push them to make that happen.
posted by metahawk at 12:27 PM on September 13, 2021 [1 favorite]

Three. Way. Call.

WHILE you are on the phone with PlanSource, get that administrator to call Ameritas while you are on the line.

This is something they need to work out between themselves, with you as witness/motivator.
posted by amtho at 1:45 PM on September 13, 2021 [1 favorite]

Response by poster: FYI, this was fixed by contacting the HR director at my old job, who reached out to the insurance people and they fixed things. Thank you for all the help!
posted by clocksock at 1:38 AM on October 21, 2021 [1 favorite]