How does COB works on HDHP

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Topic Author
Jotz16
Posts: 5
Joined: Tue Jun 22, 2021 10:52 pm

How does COB works on HDHP

Post by Jotz16 »

Hi, my wife and I found out we are pregnant a week ago. I am consuming large amounts of information to get ourselves prepared :D .

One critical item I caould't find clear information is how does Coordination of Benefits work when there are 2 High Deductible Health Plans.

My wife has a HDHP plan with her employer with a deductible of $1500 and a Maximun Out of Pocket of $3000, which only covers her. 20% copay after deductible is covered.
I have a HDHP with my employer that covers both of us and the deductible is $3940 and the Maximun Out of Pocket os $5830. 10% copay after deductible is covered.

Here some questions
1) Which insurance should be her primary? Mine or hers?
2) Do we need to pay both deductibles before the Insurance starts covering?
3) Do we have to cover the sum of both the maximum out of pocket amounts?

**For items #2 and #3 if the answer is yes then it wouldn't make sense to use my insurance as her secondary since it would only make it more expensive for us. Or I may be missing something really obvious here.

Thanks for the help
secondcor521
Posts: 1604
Joined: Wed Sep 10, 2014 4:11 pm

Re: How does COB works on HDHP

Post by secondcor521 »

I don't think you get to choose which insurance is primary and which is secondary. Usually the insurance policies have rules embedded in them for COB and that's what will happen. I think hers will be primary since she'll be the one incurring the medical bills.

As for your second and third questions, call the insurance companies involved and ask them. Most insurance companies are very comfortable with COB and how that affects deductibles and OOP maximums and should be able to explain it to you.

I would submit all claims to both insurance companies, and wait until each claim is paid by each insurance company before paying any left over balances.

If you're budgeting, remember that the baby will have it's own deductible once it's born.

Congratulations, I hope everything goes smoothly for your family.
rascott
Posts: 2957
Joined: Wed Apr 15, 2015 10:53 am

Re: How does COB works on HDHP

Post by rascott »

Strange situation.... does your employer's coverage not have a self only option? Just curious why you have her covered under two plans. I would simply use hers and hers alone.
DoubleComma
Posts: 2066
Joined: Sun Aug 23, 2020 2:23 pm

Re: How does COB works on HDHP

Post by DoubleComma »

Congratulations on the pregnancy.

While your looking into it, it might also make sense to determine now which of you will cover the baby once they are born.
lazynovice
Posts: 3369
Joined: Mon Apr 16, 2012 10:48 pm
Location: Denver area. Former Texan.

Re: How does COB works on HDHP

Post by lazynovice »

I think you are asking about coverage for the baby. You need to understand the birthday rule.

https://www.insure.com/health-insurance ... -rule.html

And a cautionary tale:

https://www.npr.org/sections/health-sho ... dical-bill

Congratulations!
Topic Author
Jotz16
Posts: 5
Joined: Tue Jun 22, 2021 10:52 pm

Re: How does COB works on HDHP

Post by Jotz16 »

rascott wrote: Wed Jun 23, 2021 8:55 pm Strange situation.... does your employer's coverage not have a self only option? Just curious why you have her covered under two plans. I would simply use hers and hers alone.
Because in certain scenarios after the deductible is cover she still has a 20% copay, and then my insurance kicks in to work on that 20%. Also I do no have to pay any extra the only difference is in the deductible which is higher. And don’t get me wrong I may be doing something stupid LOL that’s why I am seeking for advice.
Topic Author
Jotz16
Posts: 5
Joined: Tue Jun 22, 2021 10:52 pm

Re: How does COB works on HDHP

Post by Jotz16 »

DoubleComma wrote: Wed Jun 23, 2021 8:58 pm Congratulations on the pregnancy.

While your looking into it, it might also make sense to determine now which of you will cover the baby once they are born.
Yeah that is the next step. But also as advice above I will call the insurance directly to get more clarity. Right now I am only thinking about the birth costs because my wife will require a C section due to a condition she has.
Topic Author
Jotz16
Posts: 5
Joined: Tue Jun 22, 2021 10:52 pm

Re: How does COB works on HDHP

Post by Jotz16 »

lazynovice wrote: Wed Jun 23, 2021 9:21 pm I think you are asking about coverage for the baby. You need to understand the birthday rule.

https://www.insure.com/health-insurance ... -rule.html

And a cautionary tale:

https://www.npr.org/sections/health-sho ... dical-bill

Congratulations!
OMG thanks for this information, I was completely unaware of this. We are lucky we have both insurances in Massachusetts but still we will have to dig further for sure
water2357
Posts: 654
Joined: Sat Sep 12, 2020 9:24 am

Re: How does COB works on HDHP

Post by water2357 »

You need to talk to both of your employers' benefits departments and both of your insurance companies now. Anything could happen at any time, so don't wait. Find out how your wife and the baby's claims will be handled for prenatal, delivery and postnatal care. And most important, make sure the child is signed up on all the policies you have before the end of the first 30 days after birth. If you don't get the child signed up before that time period ends, the child will have a gap in coverage and that can be devastating if the child needs neonatal intensive care (NICU). NICU care for even short periods of time adds up fast, it can quickly amount to millions of dollars.

The rules governing coordination of benefits are decided by the insurance companies (or if the "insurance" claims are paid by your employer (self-funding), the employer may have some input), the rules should be written into your employer's health insurance plan policy. Contact your benefits department at work or your HR department and get a copy of each of your employers health insurance benefit plans. If you can't get the information, contact the Department of Labor. Health and Welfare plans are subject to federal law and Health Insurance is subject to both federal and state law.

You arepotentially dealing with two legal documents for each employer, one is the underlying "insurance" that your employer purchased from an insurance company for its employees (or is self-funding with an insurer acting as administrator) and a second document that is the employer provided Health and Welfare benefit plan. The HW benefit plan outlines who is eligible for coverage by the employer among other things, the employer insurance policy (contract) with an insurer outlines what services are covered, cost sharing, networks, etc. It''s possible that all you need to know is covered in one document but employer coverage is not like individual coverage. In Individual coverage, you take out the policy (contract) directly with the insurer and the insurer provides you with a copy of that policy detailing everything about your coverage. With employer coverage it can be harder to get a written copy of the details of your coverage since your employer is in between you and the insurer, particularly if your plan is self-funded.

Pay particular attention to networks. You want to make sure you choose both facilities and physicians that are in-network so you don't get hit with huge balance billing fees. Balance billing occurs when you go out of network and your policy allows the out of network providers to bill you for the difference between what the insurer will pay (allow) for a particular service and what the provider actually charges. Out of network you can get stuck for these balance billing charges. As stated by others, read the contracts, ask the insures questions, ask your employers questions, but reading the contracts yourself will provide the most reliable information (or at least read it and then ask questions).

And report all available coverage to all of your insurers up front, before there are any claims, this allows the insurers to actually set up coordination of benefits between insurers.

Possibly Mass. has more regulations on what insurers and employers must do to provide information and benefits, it may be that your state has laws about balance billing, but be sure to find out all the "gotchas" now.

And COB rules are the same across the board, they don't differ just because a plan is considered an HDHP. HDHP just allows you to open an HSA.
Topic Author
Jotz16
Posts: 5
Joined: Tue Jun 22, 2021 10:52 pm

Re: How does COB works on HDHP

Post by Jotz16 »

water2357 wrote: Wed Jun 23, 2021 10:56 pm You need to talk to both of your employers' benefits departments and both of your insurance companies now. Anything could happen at any time, so don't wait. Find out how your wife and the baby's claims will be handled for prenatal, delivery and postnatal care. And most important, make sure the child is signed up on all the policies you have before the end of the first 30 days after birth. If you don't get the child signed up before that time period ends, the child will have a gap in coverage and that can be devastating if the child needs neonatal intensive care (NICU). NICU care for even short periods of time adds up fast, it can quickly amount to millions of dollars.

The rules governing coordination of benefits are decided by the insurance companies (or if the "insurance" claims are paid by your employer (self-funding), the employer may have some input), the rules should be written into your employer's health insurance plan policy. Contact your benefits department at work or your HR department and get a copy of each of your employers health insurance benefit plans. If you can't get the information, contact the Department of Labor. Health and Welfare plans are subject to federal law and Health Insurance is subject to both federal and state law.

You arepotentially dealing with two legal documents for each employer, one is the underlying "insurance" that your employer purchased from an insurance company for its employees (or is self-funding with an insurer acting as administrator) and a second document that is the employer provided Health and Welfare benefit plan. The HW benefit plan outlines who is eligible for coverage by the employer among other things, the employer insurance policy (contract) with an insurer outlines what services are covered, cost sharing, networks, etc. It''s possible that all you need to know is covered in one document but employer coverage is not like individual coverage. In Individual coverage, you take out the policy (contract) directly with the insurer and the insurer provides you with a copy of that policy detailing everything about your coverage. With employer coverage it can be harder to get a written copy of the details of your coverage since your employer is in between you and the insurer, particularly if your plan is self-funded.

Pay particular attention to networks. You want to make sure you choose both facilities and physicians that are in-network so you don't get hit with huge balance billing fees. Balance billing occurs when you go out of network and your policy allows the out of network providers to bill you for the difference between what the insurer will pay (allow) for a particular service and what the provider actually charges. Out of network you can get stuck for these balance billing charges. As stated by others, read the contracts, ask the insures questions, ask your employers questions, but reading the contracts yourself will provide the most reliable information (or at least read it and then ask questions).

And report all available coverage to all of your insurers up front, before there are any claims, this allows the insurers to actually set up coordination of benefits between insurers.

Possibly Mass. has more regulations on what insurers and employers must do to provide information and benefits, it may be that your state has laws about balance billing, but be sure to find out all the "gotchas" now.

And COB rules are the same across the board, they don't differ just because a plan is considered an HDHP. HDHP just allows you to open an HSA.
Thanks so much for the advice. Everything is useful and 2 points that I am definitely taking. Getting the health and welfare information that is company provided support, I just subscribed to a company training for new parents in July 2nd, good thing that you pointed it out. Second one if that we made sure the service provider is in my wife’s insurance network I didn’t check mine, I will do that next. Same I will do to choose the Hospital for the birth.

Once again thanks a lot
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