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Coordination Of Benefits : When You Are Covered Under Two Or More Health Plans

When One or Both Plans are HMOs

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11/11

Applying the Coordination of Benefits provision gets more complicated when one or both of the plans is an HMO. Part of the complication lies in how health plans work in general:

  • Indemnity type plans and PPO plans are not liable to pay anything the insured would not have had to pay in the absence of the insurance. Therefore, they would only be liable for the co-pays of a managed care plan such as an HMO.
  • Managed care plans such as HMOs cover nothing for non-emergency treatment provided outside their network. As a result, they owe nothing for treatment delivered outside their network.

These rules often make the position of primary or secondary a less important factor in determining payment:

  • Indemnity plan or PPO plan with a Managed Care Plan such as an HMO.
  • The result is the same regardless of which plan is primary. It depends on where treatment was given.
    • Outside the managed care network: The indemnity/PPO plan would make full payment. The managed care coverage would pay nothing.
    • Within the Managed Care network: The managed care coverage would provide the care and the indemnity/PPO plan would pay any co-pays.

Both plans are managed care plans such as HMOs

The key is whether the treatment was provided in or out of one or both networks. If the treatment was provided:

    • A managed care type policy would pay nothing for treatment delivered outside its own network.
    • For treatment provided within both managed care networks, the primary company would provide the treatment. The secondary would pay the co-pay.

Managed care plans do not always treat the issue of duplicate coverage in the same manner as more traditional insurance plans.

Part of this is because many managed care plans are not technically insurance companies so their contracts do not conform to the insurance standard. Some managed care plans totally ignore other insurance; others will attempt to work with them. Either way, there should be little or no impact on you as the patient other than whether your co-pay is reimbursed. Most activity will be between the insurance company and the managed care company.

It would be nice to say that the secondary carrier, even if it's a managed care type company like the first carrier, would at least pay the co-pays of the primary company. However, that is not always the case. Some will, but many won't.

If the co-pays add up, it's worth pushing the secondary carrier to reimburse you.

To obtain direct reimbursement for the co-pays, be sure to get and keep a receipt from the doctor for each co-payment you make at the time of treatment. Don't expect the first carrier to be helpful because they are not really involved in the co-pay process which is between you and your doctor. Often it costs more than the $5 or $10 of the co-pay itself to bill the other carrier for the co-pays. Thus, it is usually left to you to file a claim for reimbursement of the co-pays.

When you have insurance through more than one carrier, it is preferable that you handle the submission of the claims or request reimbursement of the co-pays. If you're not up to it, ask a friend, family member or claims professional to do this for you.

Edited by David M. Morosan


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