Health Coverage – Are You Covered? Primary, Supplemental, Secondary, Tertiary, Replacement plans – Don’t Be Confused. Let’s make these complicated terms simple as water!
Primary insurance is first in line for coverage of your healthcare cost. No matter how many insurances you have, you will only have one insurance for primary health coverage. All providers must submit their claims to the primary insurance first. Your primary insurance processes claims as if it is your only insurance. It does not matter how much the provider has billed the insurance for your visit, your primary insurance has a fee for service contract with the doctor and will only allow maximum payment to be the contracted fee. Once the primary insurance finishes processing a claim, it will make a payment to the provider for the full or part of the allowable amount, then transfer rest of the allowable to you or other insurances you might have.
This is a secondary insurance which is linked to a specific primary insurance. For example, AARP is a supplemental coverage to Medicare as primary. Mercer and MediPlus are supplemental to Tricare Prime, Tricare East, and Tricare Select. Champ VA, AARP, Tricare for Life is always supplemental to Medicare. If patient changes primary coverage to a different insurance company, the existing supplemental coverage may not be valid any longer.
Suppose a patient changes primary coverage form Medicare to another insurance such as Humana, UHC, BCBS, etc., then AARP will not cover as secondary supplemental insurance any longer. Also, an important point to keep in mind, just because you have a supplemental insurance, it does not mean it will cover any left over balance from your primary insurance allowable. It all depends on what kind of plan you purchase. Supplemental plans may have high deductible or copay as well.
This is a fixed secondary coverage to your primary insurance and is not paired with any particular insurance. It stands on its own as your secondary coverage. Even if a patient chooses to change primary insurance company, it will not affect the secondary coverage. For example, if a patient has Medicare as primary and Cigna as secondary, then chooses to switch primary coverage to Humana, Cigna will still remain as the secondary insurance. Coordination of Benefit will not change.
It is very important to keep in mind to verify the coordination of benefit any time you switch to a different insurance or to a different plan under the same insurance. Many patients end up with large medical bills because they have not updated coordination of benefit when switching insurances or coverage plans. The system is not as automated as one would like to believe. Insurances require you to get in touch with them to make sure each of them know who is covering you for primary and who is responsible for secondary.
If you are eligible for Medicare or Medicaid as primary or secondary coverage, you maybe a candidate for several approved plans other than Medicare or Medicaid. These plans have been approved by government to better fit different needs of individuals, such as additional coverage for dental, hearing, and vision. Ask questions and read carefully through the benefits to make an informed decision.
Medicare eligible patients can choose from Medicare approved plans called Advantage plans, such as Humana-Medicare, BCBS-Medicare, United Healthcare-Medicare, and many more. Similarly, Medicaid program has approved plans such as Optima Health or Sentara, United Healthcare Community Plan, Aetna Better Health, Magellan Complete Care, Anthem Healthkeepers Plus, and others. Ask questions when speaking with the healthcare representative and read all information they provide to you before deciding on a coverage plan.
If you have more than two insurances, the others kick in after primary and secondary insurances have completed their processing of claims. You may choose to buy additional coverage or you maybe covered by insurances of your spouse or parents. For each additional insurances you have, make sure to contact all of them to identify the coordination of benefits. Also, make certain that your doctor’s offices know the order of coverage of your insurances.
There are no national database to coordinate all these information. Unless you take charge of your own healthcare, no one else will. Know your health benefits, such as your co-pays, deductibles, co-insurance, out-of-pocket max, coverage benefits, and coverage limitations. If your insurance allows you to create an online account, make sure to create an account so that you can log in anytime to keep track of your health benefits. Don’t wait for anyone else to find these information for you. Own your health.