3 Week Old Preemie ICU Big Bills COB Question

[yorkriver1]

First year in group insurance & with ACA, like everyone, learning details one claim at a time. Anyone familiar with coordination of benefits between individual and group plans?

Single parents, one on a BCBS group--not one of mine. Other parent came to me for lower cost option for the newborn. $400 +/MO group child premium vs. $168 for individual gold plan with $750 deductible, $3,500 MOOP. No eligibility for subsidy.

Baby can be written back to date of birth due to SEP rules on individual plan. One parent liked the gold plan insurance mentioned above, coincidentally, with the same BCBS carrier.

My question is, how can I find out if it would be worth their while to pay the first month on the group and see if it does COB with the individual.

ICU preemie bills are probably going to be very high. It would be great if the two policies could coordinate benefits at least the first month.

I don't want to tell them to avoid the group coverage if the $400 investment for 1st month on group + the $165/mo individual would save them at least $3,000 in bills. I also don't want to over complicate the situation and have them owe the $400 + for nothing if no COB. I don't have Summary of Benefits for the group coverage.

COB may complicated by both plans being with the same carrier. Example: I am still working to get a new employee on one of my groups enrolled, as prior employer was slow to cancel the COBRA when requested. Same carrier both groups, plan won't let EE be enrolled as primary EE on both plans at same time within the carrier's system. Slow to get the cancellation/enrollment to be completed. This makes me wonder about COB with 2 policies, same carrier.

Maybe if coverage is individual & group within same BCBS carrier it would work.

 

[somarco]

I never figured out why folks have double coverage. Always a mess and almost never works out the way they believe it will.

Most group plans will coordinate with individual major med plans. The birthday rule no longer applies in most cases.

When you say "single parent" do you mean two people who are not married?

For chuckles and grins let's say the group plan is primary. Group pays first. Any left over spills over to the individual plan.

If the group plan pays more than the individual plan would have paid (absent other coverage) the individual plan pays nothing.

If the individual plan is richer, the claim is determined as if there was no other coverage and then whatever the group plan pays is deducted from the amount payable by the individual plan.

 

[kgmom219]

And to further complicate matters....

Is the group fully insured? ASO? What does the group contract language say about double coverage? Just because its the same carrier does not mean the COB rules are the same.

I get what you are trying to do, but its probably not going to pay much on the secondary plan either way.

And you don't have enough information to advise them. Tell them to call the group HR department, get a copy of the policy and then look at the COB language. Then compare it to the COB language in the individual policy.

I would be shocked if the numbers added up to justify the double coverage.

 

[yorkriver1]

Thanks. Will let them know.

Now, I have another COB, this one with one of my groups. The HSA family deductible is met for 2014, plan then pays 100% in network. An adult kid in the family under 26 is the 2nd child on the family plan, so doesn't cost extra for him to be there. He also has group insurance at his job.

If his plan has a narrow network and he goes out of network, I assume his claim would be denied, and then fall to his parents' group coverage, where we know the providers he has chosen are in network.

Or, in this case, as Somarco wrote, best case, if the primary plan's payout is subracted from what the parents' plan would pay that's good. The parents' plan (my group) is now set to pay 100% of covered charges for the rest of the policy period.

The one issue would be if they absolutely expect the secondary plan to pay, so they have $0 out of pocket. No absolute guarantee, as I understand what you both have written. Best to let them know it's not a sure bet, but decent possibility.

 

[somarco]

OON claims are not automatically denied unless it is an HMO. Even then, it is not necessarily a denial.

Best to let them know it's not a sure bet, but decent possibility.

I wouldn't even do that.

Anticipating how (or if) a carrier will pay a claim is like smoking while pumping gas.

 

[yorkriver1]

Well if you see a news story about a loud boom and a big smoke cloud, you'll know I didn't take your advice, but I will.
Claims determination is "not at my pay grade". As long as client notifies both carriers of other coverage as most will require, and gives both cards to service providers, which is what BCBS stated, then the chips will fall as they may.
For the client with 100% after deductible and free coverage for the dependent nothing ventured, nothing gained. The kid needs to see a good doc, so will do so anyway.

 

[somarco]

Just saying .................

Not too often, but more than once, I have been on the receiving end of a tirade because I didn't have all the relevant facts. I learned long ago to keep my mouth shut, or give an ambiguous answer and leave it at that.

COB is pretty straight forward but you never know what you can run into.

 

[yorkriver1]

Have advised preemie parents to carefully review the current employer coverage against the individual gold plan.
The other situation, more likely with the HSA deductible having been met, but must manage expectations by not promising how things will/should go.