Navigating Two Private Insurances (Feeling a bit lost with insurance details)
I’m new to the private insurance realm, and I would greatly appreciate any insights or answers to my questions. Here’s the situation I’m dealing with:
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Priority Health – HMO with a $1,300 family deductible (offered through my employer, Corewell Health)
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Anthem – Healthsync POS with HSAS featuring a $6,000 family deductible (through my husband’s employer in Indiana)
Questions:
- How do deductibles work?
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The policy states, “You must meet the deductible before coverage begins.” I’ve had Priority Health since January 1, 2025 (Anthem activated on March 1, 2025). Priority claims that my family deductible of $1,300 has been met, but I haven’t spent anywhere near that on copays or prescriptions. While I’m happy about this, it makes me wonder if I had some form of coverage already.
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Should I inform both insurance companies about coordinating benefits?
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Can I choose which insurance is primary for doctor visits and prescriptions?
- Does it matter which one is designated as primary and which as secondary?
I might be jumping to conclusions, but even with the higher deductible, my husband’s Anthem insurance seems better overall.
- Understanding Insurance Calculations:
- I recently filled a prescription, and the pharmacy processed claims like this:
- Priority Insurance (primary): $15 copay
- Anthem Insurance (secondary): $11 copay
- The pharmacy combined these to a total copay of $7. Was this processed correctly? With two private insurances, shouldn’t the prescription ideally be covered entirely, resulting in a $0 copay? Will I still be required to pay an office-visit copay for in-network doctor appointments under both plans?
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I feel if I’m paying full premiums for both insurers, I should get full coverage from them together.
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Do I need to file claims with both insurances for prescriptions?
- My husband requires disposable insulin pumps that needed prior authorization, which took months due to communication issues between Corewell Health and Priority Insurance. Thankfully, Priority Health now fully covers these pumps. Here’s my query: Until the prior authorization expires, does he need to claim through Anthem for refills? Note that Anthem started providing coverage on March 1, 2025, and wasn’t involved in the initial prior authorization.
- I’ve noticed several prescriptions that Priority doesn’t cover but Anthem does. Having two insurance plans can feel like a mixed blessing. My main reason for holding both insurances is to navigate the differences in prescription coverage.
Any advice or clarification would be appreciated! Thank you!
It sounds like you’re navigating a complex situation with two private insurance plans. Let’s break down your questions to clarify how things work:
1. How do deductibles work?
A deductible is the amount you need to pay out of pocket for healthcare services before your insurance starts to pay. If Priority Health is stating that you have met your $1,300 deductible, it could be due to a couple of reasons:
2. Coordination of Benefits
Yes, it’s typically beneficial to notify both insurance companies about each other so they can coordinate benefits. This is known as “Coordination of Benefits” (COB) and ensures that each insurance knows which one is considered primary (pays first) and secondary. Generally, the primary insurance pays first, and the secondary insurance may cover some or all of the remaining costs.
3. Choosing Primary Insurance
You generally don’t choose which insurance is primary; it depends on certain factors like whether you are the employee or dependent, and the policies of both employers. However, with both names listed, one will usually be designated as primary based on the specifics of your policies and state laws. It is important to check with both insurers and see who is considered primary and secondary for procedures and prescriptions.
4. Insurance Math and Copays
With two insurances, it’s common for the primary insurance to cover part of the costs and for the secondary insurance to cover additional costs. The combined copay of $7 you received from the pharmacy does sound appropriate. However, it doesn’t mean the prescription will always be $0; this depends on the policies of the insurance companies.
And yes, usually, you are expected to pay a copay for office visits according to the terms of each insurance plan regardless of whether you have two insurances.
5. Filing Claims for Prescriptions
If Priority Health is currently covering the disposable insulin pumps under the previous prior authorization, you typically would continue using them for those refills when they are fully covered unless there’s a specific reason to involve Anthem. Always follow the guidelines stated during the prior authorization and double-check with both insurers about any requirements, especially given the change in insurance.
In summary, managing two insurance plans can definitely be complicated, but understanding how deductibles, coordination of benefits, and coverage work can help you make the most of your coverage. Don’t hesitate to reach out to both insurance providers for clarification regarding your specific situation, especially in cases of uncertainty about coverage and claims processing.