Insurance question---double insured

[Scarlett]

Dh's new job has medical insurance :D. He put all of us (him, me and our 3 boys) on his insurance. My ds11 is already covered by his dad (court ordered). I called XH's insurance company and they said they would continue to be the primary provider of coverage due to the court order.

 

Dh's boys live with their mom. She recently put them on her new husband's insurance...I think it was effective Jan 1. (she keeps refusing/failing/forgetting to give dh insurance cards). Their divorce decree has no provision for who is responsible for their insurance.

 

Does anyone know which insurance company will be primary?

 

When I was married to ds's dad, I briefly had ds double covered (before I quit my job). At that time the insurance companies decided that question by using the parent whose birthday fell first in the caledar year as primary.

[Lara in Colo]

Usually they just fight it out and nothing gets paid.

 

I would find out which is best for the money and cancel the other.

 

or choose the most stable employment (ie less likely to lose coverage)

[Scarlett]

Usually they just fight it out and nothing gets paid.

 

I would find out which is best for the money and cancel the other.

 

or choose the most stable employment (ie less likely to lose coverage)

 

The problem is that dh's wants to BE SURE his boys are covered. He can't trust his XW to do that. They were uninsured for over a year. If they had lived with us they would have qualified for state coverage (free). We think XW would have qualified but she was extrembly hostile to dh about it telling him it was 'his problem'.

 

Adding my ds to dh's plan cost nothing more than adding dh's 2 boys. And my XH's plan has a $750 deductible and 20% co pay so if dh's insurance will pick that up it will be great.

 

Dss15 has to have an operation this year and it will be REALLY beneficial if there is double coverage. I hope.

 

I had no trouble at all when ds had double coverage when he was a baby and I was still married to XH. Every thing was covered 100%.

[Scarlett]

I found this http://www.nalc.org/depart/hbp/news/Forms/Medicare/Double%20Coverage.html

 

 

 

Who Pays First?

 

 

Recognizing the complexities of Double Coverage, the health insurance industry with the cooperation of the National Association of Insurance Commissioners (NAIC) developed a system for determining the primary payer which is called the "Order of Benefit Determination." Our contract requires the Plan to follow these guidelines.

 

The Plan that covers the patient as the employee (member) pays before the plan that covers the patient as a dependent;

 

For dependent children the "birthday rule" governs. If a child is covered under both parents' insurance companies (divorced or separated parents excluded), the primary carrier is determined by the plan covering the parent whose birthday, excluding year of birth, occurs earlier in a calendar year. If the other insurance company does not have this provision, the father's plan may be primary;

 

When the parents are separated or divorced, the primary carrier is the plan covering the child as a dependent of the parent with custody (unless this is contrary to a court determination). If the parent with custody has remarried, the plan covering the step-parent pays benefits second, and the plan covering the parent without custody pays benefits third. If a court awards joint custody the "birthday rule" applies;

 

 

The plan covering the person as an active employee pays benefits first.The plan covering the person as a laid off or retired employee pays benefits second;

 

The plan covering the person through temporary continuation of coverage (TCC) is ALWAYS secondary;

 

If none of the above apply, the plan that has insured the patient longer is primary;

 

If no other rules apply, then the medical expenses are shared equally between all plans.

[Carol in Cal.]

Be aware that 'double coverage' doesn't always work out to 'more coverage'. Often the plans have some clause that prevents payments totalling more than that one plan would cover. IOW, you might not save yourself any OOP expense just by virtue of having double coverage. So check the fine print.

[Scarlett]

I found this http://www.nalc.org/depart/hbp/news/Forms/Medicare/Double%20Coverage.html

 

 

 

Who Pays First?

 

 

Recognizing the complexities of Double Coverage, the health insurance industry with the cooperation of the National Association of Insurance Commissioners (NAIC) developed a system for determining the primary payer which is called the "Order of Benefit Determination." Our contract requires the Plan to follow these guidelines.

 

The Plan that covers the patient as the employee (member) pays before the plan that covers the patient as a dependent;

 

For dependent children the "birthday rule" governs. If a child is covered under both parents' insurance companies (divorced or separated parents excluded), the primary carrier is determined by the plan covering the parent whose birthday, excluding year of birth, occurs earlier in a calendar year. If the other insurance company does not have this provision, the father's plan may be primary;

 

When the parents are separated or divorced, the primary carrier is the plan covering the child as a dependent of the parent with custody (unless this is contrary to a court determination). If the parent with custody has remarried, the plan covering the step-parent pays benefits second, and the plan covering the parent without custody pays benefits third. If a court awards joint custody the "birthday rule" applies;

 

The plan covering the person as an active employee pays benefits first.The plan covering the person as a laid off or retired employee pays benefits second;

 

The plan covering the person through temporary continuation of coverage (TCC) is ALWAYS secondary;

 

If none of the above apply, the plan that has insured the patient longer is primary;

 

If no other rules apply, then the medical expenses are shared equally between all plans.

 

ds11 is easy since there is a court order. For dh's boys though it seems tricky...likely their mom will be primary since she has physical custody...but they have joint legal custody.

 

What a mess.

[Scarlett]

Be aware that 'double coverage' doesn't always work out to 'more coverage'. Often the plans have some clause that prevents payments totalling more than that one plan would cover. IOW, you might not save yourself any OOP expense just by virtue of having double coverage. So check the fine print.

 

That is some of what I am finding on the net. I guess it depends on the plan/carrier. Ugh.

[Scarlett]

Be aware that 'double coverage' doesn't always work out to 'more coverage'. Often the plans have some clause that prevents payments totalling more than that one plan would cover. IOW, you might not save yourself any OOP expense just by virtue of having double coverage. So check the fine print.

 

It would be easier if dh's XH would provide info! So frustrating!

[Carol in Cal.]

It would be easier if dh's XH would provide info! So frustrating!

 

You wouldn't be able to believe or count on her word anyway. Let it go. Be effective. It totally bites, but it's the right thing to do to take care of business for your children.

[Scarlett]

You wouldn't be able to believe or count on her word anyway. Let it go. Be effective. It totally bites, but it's the right thing to do to take care of business for your children.

 

Right. That is why dh wanted to cover them regardless of what she has done. But we gave her insurance cards so she knows what their coverage is.

 

I think she will be compelled to give dh the info at some point....because the insurance companies will have to coordinate benefits.

 

She didn't know dh was getting insurance on the boys and she 'told' him he would have to pay half the premium on her husband's plan. (was NOT gonna happen) All she provided was a handwritten sheet of paper...she wrote '$86.00---half of insurance premium--due monthly.'

 

Yeah, like dh would a)pay half the premium on her husband's plan or b)take her word for the amount.

 

It didn't matter because he then told her, 'oh, I have them insured too, here are their cards.' She was :001_huh: speechless.

[Wheres Toto]

If there is no court order specifying and there is joint legal custody and neither parent is designated as the custodial parent they will usually use the birthday rule.

 

I have this with my oldest. She is covered under my dh's plan and for a little while, was covered under her father's plan. It became very messed up since I'm the one who takes her to the doctor but exh was primary since his birthday, and his wife who also had insurance for a while, are both earlier than mine in the year. He didn't keep me updated on the plans (with numerous lay-offs and job changes) or give me access to the insurance card. I finally told him to either drop her off his plans and not add her to any new plans or make sure I had what I needed, otherwise he would be responsible for any bills that did not get paid due to incorrect information. He chose to drop her from his insurance.

[Scarlett]

If there is no court order specifying and there is joint legal custody and neither parent is designated as the custodial parent they will usually use the birthday rule.

 

I have this with my oldest. She is covered under my dh's plan and for a little while, was covered under her father's plan. It became very messed up since I'm the one who takes her to the doctor but exh was primary since his birthday, and his wife who also had insurance for a while, are both earlier than mine in the year. He didn't keep me updated on the plans (with numerous lay-offs and job changes) or give me access to the insurance card. I finally told him to either drop her off his plans and not add her to any new plans or make sure I had what I needed, otherwise he would be responsible for any bills that did not get paid due to incorrect information. He chose to drop her from his insurance.

 

This is the kind of mess I fear will happen...which is why I am trying to figure out how it should work. His XW has primary custody. So I am pretty sure based on that she will be primary on insurance. (although it isn't her plan--it is her husband's so will that matter?) If it is based on birthday rule then dh would be primary.

Edited January 25, 2012 by Scarlett
XW not XH!

[Carol in Cal.]

I am kind of surprised that her husband's plan will take them if he is not an adoptive parent.

[Wheres Toto]

That may vary from state to state but here "my" insurance can be my husbands through his employer despite him not having adopted my dd.

 

The birthday rule goes by the covered employee so it's actually dh's birthday not mine that they would use for eligibility determinations.

 

If one parent has primary custody usually they will be primary for insurance as well.

[SonshineLearner]

If the court doesn't decree who's responsibility it is, I think it falls by DOB of the 2 involved. :) I've recently thought of scanning all insurance cards and emailing them to myself. I have so many, and this way I can always access them :)

[Scarlett]

I am kind of surprised that her husband's plan will take them if he is not an adoptive parent.

 

My ds is a dependent of my dh. I have sole custody. I assume that is why my dh can insure him.

[Scarlett]

That may vary from state to state but here "my" insurance can be my husbands through his employer despite him not having adopted my dd.

 

 

 

If one parent has primary custody usually they will be primary for insurance as well.

 

That is what I thought, but dh called his insurance today and they asked

1) Where the boys live (with their mom)

2) Is there a court order re insurance coverage (no)

 

And then told him his insurance would be primary because of the bd rule.

 

Weird. But oh, well.

[Scarlett]

If the court doesn't decree who's responsibility it is, I think it falls by DOB of the 2 involved. :)

 

Which two? Dh and his XW even though she is not the employee on the plan she has the boys on? (she has them on her dh's plan)

 

It gets so confusing.

[Scarlett]

Courts can legally order it.

 

? What do you mean?

[Scarlett]

I read and responded too quickly (so I'm partly talking out of my blow hole). I just know that courts can order coverage that goes against what an insurance company can set in terms of their coverage rules.

 

I don't see why they can't be covered if you are married and they live with you and your husband (irregardless if they are his children or not). They are dependent children right? I've never encountered a situation where we've been asked to prove that the children are ours. KWIM?

 

Oh. Well, dh's boys live with their mom and stepdad and he (step dad) is covering the boys on his insurance. And dh is covering them on his. My ds lives with me and dh and he is covered by his dad's insurance and my dh's.

 

Basically you can cover them if they are your child (regardless of where they live) or they are your dependent (living with you).

[*********]

Right. That is why dh wanted to cover them regardless of what she has done. But we gave her insurance cards so she knows what their coverage is.

 

I think she will be compelled to give dh the info at some point....because the insurance companies will have to coordinate benefits.

 

She didn't know dh was getting insurance on the boys and she 'told' him he would have to pay half the premium on her husband's plan. (was NOT gonna happen) All she provided was a handwritten sheet of paper...she wrote '$86.00---half of insurance premium--due monthly.'

 

Yeah, like dh would a)pay half the premium on her husband's plan or b)take her word for the amount.

 

It didn't matter because he then told her, 'oh, I have them insured too, here are their cards.' She was :001_huh: speechless.

 

If there is no court order specifying and there is joint legal custody and neither parent is designated as the custodial parent they will usually use the birthday rule.

 

I have this with my oldest. She is covered under my dh's plan and for a little while, was covered under her father's plan. It became very messed up since I'm the one who takes her to the doctor but exh was primary since his birthday, and his wife who also had insurance for a while, are both earlier than mine in the year. He didn't keep me updated on the plans (with numerous lay-offs and job changes) or give me access to the insurance card. I finally told him to either drop her off his plans and not add her to any new plans or make sure I had what I needed, otherwise he would be responsible for any bills that did not get paid due to incorrect information. He chose to drop her from his insurance.

 

This is the kind of mess I fear will happen...which is why I am trying to figure out how it should work. His XW has primary custody. So I am pretty sure based on that she will be primary on insurance. (although it isn't her plan--it is her husband's so will that matter?) If it is based on birthday rule then dh would be primary.

 

Scarlett, we JUST went through this, so I can share what I know.

 

Dh has ALWAYS had his older kids on his insurance. Both he and their mother have a court order to put the kids on any insurance that is available to them. Their mother refused to cover them for YEARS, even though she had coverage. Which meant dh paid for coverage for them as well as his more than 50% responsibility (again per court order) of uncovered expenses. So I totally agree that your dh is doing the right thing by covering his kids regardless of what his xw says she's doing. BTW, we STILL don't have insurance cards for the coverage that the stepkids mom has for them; she gives us the same runaround.

 

Anyway, what I learned from our insurance company and the NIGHTMARE it was getting them to co-ordinate with their mom's insurance company:

 

They will use the 'birthday rule' IF both parents have joint legal AND joint physical custody. If your dh's ex has PHYSICAL custody (which is what I assume you mean by 'primary custody') than HER insurance will be primary.

 

I was told that this is the INDUSTRY standard.

 

What I would reccommend is getting all this straightened out with your insurance company BEFORE something big comes up. Contact the insurance company your dh has his kids on, and give them any and all info you have regarding your dh's ex's insurance policy she claims the kids are on. Hopefully, you have at least a name of the insurance company and the policy/contract number. They should be able to take it from there. They may ask you to mail/fax copies of the court orders stating who has physical/legal custody, as well as any part concerning who must carry the children on their insurance. If you have NO info regarding your dh's ex's insurance, and she won't give it to you/gives you the runaround, I'd tell her you're giving your insurance company her phone number, because they need to contact her for the info. That's really all you can do in that regard.

 

Our insurance company and the stepkid's mom's insurance company took MONTHS arguing back and forth, deciding who was primary. It was right there in black and white, but their mom's insurance kept dragging it's feet and complaining until it had all but a pint of blood, I swear. In the end, they conceeded that they are primary, and all the backlog of the kid's bills got paid. But their doctor was getting irritated that they had outstanding bills not paid, and kept sending US copies of bills from their MOM taking them in, asking us to pay. Yeah, right. :glare: I'm sure if we did that, and then insurance paid them later, we'd never see a cent of our money back.

 

Good luck. Really, you want to get the ball rolling sooner rather than later. The whole thing was such a huge pain in the neck, dh told their mom to feel free to drop them off her insurance, since ours pays well when it's not fighting with another insurance company. :tongue_smilie:

Edited January 26, 2012 by bethanyniez

[Scarlett]

Scarlett, we JUST went through this, so I can share what I know.

 

Dh has ALWAYS had his older kids on his insurance. Both he and their mother have a court order to put the kids on any insurance that is available to them. Their mother refused to cover them for YEARS, even though she had coverage. Which meant dh paid for coverage for them as well as his more than 50% responsibility (again per court order) of uncovered expenses. So I totally agree that your dh is doing the right thing by covering his kids regardless of what his xw says she's doing. BTW, we STILL don't have insurance cards for the coverage that the stepkids mom has for them; she gives us the same runaround.

 

Anyway, what I learned from our insurance company and the NIGHTMARE it was getting them to co-ordinate with their mom's insurance company:

 

They will use the 'birthday rule' IF both parents have joint legal AND joint physical custody. If your dh's ex has PHYSICAL custody (which is what I assume you mean by 'primary custody') than HER insurance will be primary.

 

I was told that this is the INDUSTRY standard.

 

What I would reccommend is getting all this straightened out with your insurance company BEFORE something big comes up. Contact the insurance company your dh has his kids on, and give them any and all info you have regarding your dh's ex's insurance policy she claims the kids are on. Hopefully, you have at least a name of the insurance company and the policy/contract number. They should be able to take it from there. They may ask you to mail/fax copies of the court orders stating who has physical/legal custody, as well as any part concerning who must carry the children on their insurance. If you have NO info regarding your dh's ex's insurance, and she won't give it to you/gives you the runaround, I'd tell her you're giving your insurance company her phone number, because they need to contact her for the info. That's really all you can do in that regard.

 

Our insurance company and the stepkid's mom's insurance company took MONTHS arguing back and forth, deciding who was primary. It was right there in black and white, but their mom's insurance kept dragging it's feet and complaining until it had all but a pint of blood, I swear. In the end, they conceeded that they are primary, and all the backlog of the kid's bills got paid. But their doctor was getting irritated that they had outstanding bills not paid, and kept sending US copies of bills from their MOM taking them in, asking us to pay. Yeah, right. :glare: I'm sure if we did that, and then insurance paid them later, we'd never see a cent of our money back.

 

Good luck. Really, you want to get the ball rolling sooner rather than later. The whole thing was such a huge pain in the neck, dh told their mom to feel free to drop them off her insurance, since ours pays well when it's not fighting with another insurance company. :tongue_smilie:

 

Oh boy. What you are saying here makes sense to me. She has physical custody so I'm thinking she should be primary. I don't know if you saw my post above after dh talked to his insurance today but THEY (dh's insurance) told dh he (dh's insurance) would be primary based on the birthday rule.

 

Dss15 goes to the doctor next Monday....so I guess we will see how it goes then.

 

What I then fear is her getting her insurance to pick up the difference of what ours doesn't pay. Hopefully since she has custody she will be legally responsible for the bills and that may motivate her to file the claims for secondary coverage. (we will still be responsible for 1/2 of what isn't covered by both insurances....and so will have to make her prove it wasn't covered before reimbursing her).

 

Stepmothering ain't for sissies!

[Scarlett]

Scarlett, we JUST went through this, so I can share what I know.

Good luck. Really, you want to get the ball rolling sooner rather than later. The whole thing was such a huge pain in the neck, dh told their mom to feel free to drop them off her insurance, since ours pays well when it's not fighting with another insurance company. :tongue_smilie:

 

I just read your entire post to my dh and he is going to call his insurance again tomorrow and verify.

 

Thanks for your help Bethany.

[*********]

Oh boy. What you are saying here makes sense to me. She has physical custody so I'm thinking she should be primary. I don't know if you saw my post above after dh talked to his insurance today but THEY (dh's insurance) told dh he (dh's insurance) would be primary based on the birthday rule.

 

Dss15 goes to the doctor next Monday....so I guess we will see how it goes then.

 

What I then fear is her getting her insurance to pick up the difference of what ours doesn't pay. Hopefully since she has custody she will be legally responsible for the bills and that may motivate her to file the claims for secondary coverage. (we will still be responsible for 1/2 of what isn't covered by both insurances....and so will have to make her prove it wasn't covered before reimbursing her).

 

Stepmothering ain't for sissies!

 

Scarlett, I forgot to come back to this thread yesterday...

 

Only thing I'd add is regarding the first bolded part:

 

My understanding is that MOST doctor's offices hold whomever signs their 'I will pay for services not covered by insurance for this patient' form responsible for payment. Your dss's doctor doesn't care who has physical custody. They likely have a form in his file signed by either his mother or your dh, saying they'll be responsible for payment to the doctor. It was likely whoever took the child to the doctor initially, and got him all 'signed up'.

 

Now, my stepkid's mom has given dh's info to every single last doctor she's taken the kids to. She's even 'neglected' to pay even HER part of the co-pay when she takes them, then gives the doctor's office DH's name and address to send the bill to. :glare: It's all shaken out in the end, but it can be a hassle.

 

So, if your dss's doctor's office is all set up to send the bill to his mother's name and address, I'd just go that route. And make her come to you for reimbursement. That way, you have some sort of leverage regarding getting her insurance info to the doctor/getting the primary/secondary insurance figured out. BTW, she shouldn't be responsible for submitting the claims to her insurance, regardless of if it's primary or secondary. The boy's doctor's office should be able to take care of that. But it's EASIER for the doctor's office to do all that if you can tell them who is primary and who is secondary when you go in for the visit.

 

And about that last bolded line; AIN'T THAT THE TRUTH. :D

[*********]

Scarlett, here's the actual policy for determining coordination of benefits. This was on our insurance's website, and is what I was told is the industry wide standard:

 

(6) The Birthday Rule applies when determining which plan is primary for dependent children. The child’s primary plan is the plan of the person (parent, stepparent, etc.) whose birthday falls earlier in the calendar year (month and day only). If the birthdays of the persons covering the dependent child are on the same date, the plan that has covered the child longer is primary. This subsection (6) does not apply if subsection (7) below applies.

(7) For dependent children of divorced parents, legally separated parents, or unmarried parents who do not reside in the same household, benefits are coordinated as follows:

(a) If a court order assigns responsibility for providing health benefits to one parent, that parent’s plan is primary.

(b) If a court order assigns responsibility for providing health benefits to both parents, the primary plan is determined in the following order:

(i.) Parent with physical custody.

(ii.) Stepparent with physical custody.

(iii.) Parent without physical custody.

(iv.) Stepparent without physical custody.

This order above does not apply, however, when parents have joint physical custody. In such cases, the Birthday Rule in subsection (6) above applies.

© If a court order fails to assign responsibility for providing health benefits to either parent or if no court order exists, health benefits are determined according to custody, as described in subsection (7)(b). However, in cases of joint physical custody, the Birthday Rule in subsection (6) above applies.

[fhjmom]

I am kind of surprised that her husband's plan will take them if he is not an adoptive parent.

 

DH's insurance plans has always covered my DS. When filling out insurance enrollment forms there is always a choice for "step-child" in the field for "relationship to insured", and that is what we mark. I never even thought to find this unusual. :confused:

[Scarlett]

Scarlett, here's the actual policy for determining coordination of benefits. This was on our insurance's website, and is what I was told is the industry wide standard:

 

 

 

(6) The Birthday Rule applies when determining which plan is primary for dependent children. The child’s primary plan is the plan of the person (parent, stepparent, etc.) whose birthday falls earlier in the calendar year (month and day only). If the birthdays of the persons covering the dependent child are on the same date, the plan that has covered the child longer is primary. This subsection (6) does not apply if subsection (7) below applies.

(7) For dependent children of divorced parents, legally separated parents, or unmarried parents who do not reside in the same household, benefits are coordinated as follows:

(a) If a court order assigns responsibility for providing health benefits to one parent, that parent’s plan is primary.

(b) If a court order assigns responsibility for providing health benefits to both parents, the primary plan is determined in the following order:

(i.) Parent with physical custody.

(ii.) Stepparent with physical custody.

(iii.) Parent without physical custody.

(iv.) Stepparent without physical custody.

This order above does not apply, however, when parents have joint physical custody. In such cases, the Birthday Rule in subsection (6) above applies.

© If a court order fails to assign responsibility for providing health benefits to either parent or if no court order exists, health benefits are determined according to custody, as described in subsection (7)(b). However, in cases of joint physical custody, the Birthday Rule in subsection (6) above applies.

 

Bethany, I read a similar 'standard' on another website and it indicated that it coordinated with some national organization of insurance commissioners. I read your entire post to dh last night and so he again today called his insurance company back and they ASSURED him that they will be primary based upon the birthday rule EVEN THOUGH their mother has physical custody.

 

The XW will be taking their 15 year old to the doctor (an appt with a specialized that will require surgery soon) on Monday so dh wants to be able to tell her what she should tell the doctor about that issue. Also, his insurance told him they will need the name/policy info on the XW/Stepdad insurance....so he will have to have another conversation with her about getting that info. Only been trying to get it out of her since July. :glare:

 

As for my ds, dh's insurance told him they would like to have a copy of my divorce decree (which orders XH to pay for insurance) and that insurance info too.

 

Thanks for your help on this.

 

When I told dh 'step-parenting aint for sissies' he just :glare: at me (with love of course) and said, 'yeah, I know.' LOL

[Scarlett]

Bethany,

I thought you would get a :001_huh: out of this....

 

Dh's XW is taking their son to the doctor today. You know for months we have asked for the name of the insurance her husband has on them. Nothing. Dh's insurance said they would be primary but that they need the name of the insurance company that will be secondary. Dh asked his XW that today and she refused to give it to him. She said, 'for some reason my husband doesn't want you to have that info.'

 

:001_huh:

 

And yet....they want dh to pay half the premium.

 

And yet...they are dh's children...so of course he has the right/need to know who is insuring them.

 

Very strange I think. Makes us wonder what he has to hide.

 

They also refuse to give us their P.O. Box. What POSSIBLE reason could anyone have for keeping that a secret?