In today's world, it's common for both spouses to work outside the home. This often leads to families having duplicate health insurance coverage, which can be a source of confusion for patients and physicians alike. If you or your children have coverage by more than one group health insurance plan, understanding coordination of benefits will reduce the likelihood of errors in processing your family's claims.
Primary Carrier
When you receive treatment, and you have coverage under two health insurance plans, the plan that pays benefits first is the primary carrier. This plan pays the bill up to the maximum that it permits. Your own employer's plan is always primary, regardless of the type of policy, deductibles, co-pays and limitations.
Secondary Carrier
If medical costs remain after the primary plan pays, the health care provider submits the balance to the secondary carrier. HCVAdvocate.com explains, "The other plan will pay what is remaining of the total medical bill, up to the maximum amount it would have paid if it were the only insurance company involved."
Children
The "birthday rule" determines which carrier pays for services rendered to children covered by two group health insurance plans. Under the birthday rule, the plan covering the parent whose birthday is earlier in the calendar year is primary. The actual year in which the parents were born has no bearing on the birthday rule.
Medicare
If you have coverage by both Medicare and a group health insurance policy, the number of employees in your company determines the primary carrier. Group medical plans for companies with fewer than 20 employees are always secondary, while plans for companies with more than 20 workers are primary.
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