Duel (oops dual) insurance coverage, how does it work?

With insurance decisions being made this time of year I'm curious:

If you are covered by more than one insurance company (i.e. retiree coverage and current employer's coverage), how would CPAP coverage work?
Is there a primary/secondary provider in this case?
Would/could the treatment be wholly separate from one company to the other?
What happens if one company only deals with one DME and the other gives you a wider choice of DMEs with more machine options? Can you pick and choose OR choose both?

thanks!

It is different depending on the size of your employer and if you or your spouse is working.
Other factors could come into play. Those little devils don't like "easy".

No doubt one would have to be the primary but I am not sure how that is determined. I would for sure want to talk to each to find out their details.

There is also this thing called, "coordination of benefits",
that one or the other will use to try to weasel out of their responsibility.

One will be primary and the other will be secondary insurance. Which is Which? You will need to contact your two insurance companies to see what their policy says. It is different with different insurances. If you had Medicare but your wife is working, it would depend upon how many employees are at your wifes workplace to determine which is which. Call both insurances cuz it can get complicated.

Would it matter if the same person is the primary policy holder for both insurance companies?

Ogeo wrote:it would depend upon how many employees are at your wife's workplace

Why the question about how many employees a company has to determine primary insurance provider? Is that one of the criteria? That surprises me...

I was told that the company that you are insured with first (chronologically) is considered the primary and that if it is an HMO and you sought services outside the HMO then the secondary provider would be tapped to pay. True?

chunkyfrog wrote:There is also this thing called, "coordination of benefits",
that one or the other will use to try to weasel out of their responsibility.

OR do the insurance companies do all the deal making behind the scenes since you are 'tracked' via your social security number and they have all our info at their fingertips and they decide between themselves "it's your turn this to pay this time"?

Supposedly there are set rules, but it doesn't always seem that way.
Since somebody is employed, a chat with their benefits manager should clear things up.
Get the full poop in writing, because it is complicated.

sleep_quest wrote:Would it matter if the same person is the primary policy holder for both insurance companies?

You will still have to contact the companies to see who is primary and who is secondary. If they are both the policy of the retiree who is now working, most likely the current work policy would be primary but not always.

Ogeo wrote:it would depend upon how many employees are at your wife's workplace

Why the question about how many employees a company has to determine primary insurance provider? Is that one of the criteria? That surprises me...

If you have Medicare insurance - there is a pdf that explains it. I just googled Medicare primary and secondary and it came up. http://www.medicare.gov/Pubs/pdf/02179.pdf

I was told that the company that you are insured with first (chronologically) is considered the primary and that if it is an HMO and you sought services outside the HMO then the secondary provider would be tapped to pay. True?

HMO's usually follow medicare guidelines but the only way to know for sure is to call them. As a biller, I spent many hours on the phone to insurance companies trying to sort it out for some of our customers.

chunkyfrog wrote:There is also this thing called, "coordination of benefits",
that one or the other will use to try to weasel out of their responsibility.

OR do the insurance companies do all the deal making behind the scenes since you are 'tracked' via your social security number and they have all our info at their fingertips and they decide between themselves "it's your turn this to pay this time"?

It should all be in print somewhere and you should be able to get a copy of their guidelines for determining who is primary and who is secondary. It will take an effort on your part to do so though.

As I understand it, and I may be wrong, the coverage (coordination of benefits) usually dictates that insurance thru the working coveree is primary & retiree is secondary. Unless you have Medicare, in which case Medicare is after working & before retiree.

This could just be how mine was handled, but it was explained to me that these are pretty much the standard guidelines.

Jen

Thanks for the replies. I'm trying to do my homework in advance of making insurance decisions.

Nope, not on Medicare so we're dealing with two private insurance companies. Kaiser is one and the other is as yet unknown because it won't be chosen until next month. I called Kaiser yesterday and the rep there was the one that told me the company that you are insured with first (chronologically) is considered the primary. That just didn't make sense to me but what do I know.

If I want to use services outside of Kaiser, which limits me to using Apria as the DME, I assume the new insurance company would kick in at some point but I won't be able to confirm directly until next month when the options for providers is made available.

sleep_quest wrote:Kaiser is one and the other is as yet unknown because it won't be chosen until next month.

Choose carefully, Kaiser is completely different.

One thing is consistent when dealing with two insurance companies: any claims will take a lot longer,
as they have to be submitted to each insurer consecutively, starting with the "primary"- (AFAIK)
-even if you already know they will not cover a provider or service.

I'd like to see two insurance companies duel... perhaps to the death...

Ahh... Kaiser is a breed unto itself. They are real sticky to work with. Good Luck.

Things to find out when you know who your secondary insurance is: Will Kaiser automatically send the claim to the secondary after they process the claim or will the provider have to submit to the secondary? Will the secondary insurance cover the 20% that Kaiser does not cover or will they consider it duplication of benefits and not cover any of the 20%? I've seen that before with a secondary insurance. Some secondary insurances will cover all the 20% others a percentage and some won't cover any on certain services while other services they will. Hopefully yours will cover the copay left by Kaiser.

Good Luck.

I was wondering myself if the typo in your title was intentional--they will duel it out. The only problem is that you will be standing in between them.

As for Kaiser, whether Kaiser is your primary or secondary, there's gonna be trouble if you don't use Crapria. Not only must you use Crapria with Kaiser, but you don't even get to use the normal, lousy Crapria, you have to use Kaiser's interface with Crapria, because KAISER is your DME, not Crapria. Crapria is merely the supplier. So Kaiser has a formulary, and most things are NOT on it. For example, there's a limited choice of masks on the formulary, and Kaiser SAYS what you get as far as machines--you only get an APAP if Kaiser says you do. And you get NO choice in brand or model, Kaiser dictates that. Your mask has to be specified on the doctor's order, if you want to switch masks you have to go through the sleep lab to get your order changed. A PITA.

So if Kaiser is your primary, they will only pay if you get it through them via Crapria, on their formulary and order. Whether your secondary insurance will kick in and pay the rest is unknown.

If your other insurer is primary, don't expect Kaiser to pay a penny, UNLESS you go through Kaiser to get what's on their formulary from Crapria and your primary insurance pays first.

A HUGE mess. No fun.