Navigating Dual Private Insurance: Seeking Clarity
I’m new to the world of private insurance and could use some guidance. Here’s my current situation:
– Priority Health – HMO ($1,300 family deductible) – Through my employer, Corewell Health
– State of Indiana Anthem – Healthsync POS with HSA ($6,000 family deductible) – Through my husband’s employer in Indiana
I have a few questions that I’m hoping someone can help me with:
1. How do deductibles actually work?
The policy states, “You must meet the deductible before coverage kicks in.” I’ve had Priority Health since January 1, 2025, but Anthem just became active on March 1, 2025. Priority is claiming that I’ve met my $1,300 family deductible, yet I feel like I haven’t incurred that much in office visit copays or prescriptions. I’m glad, but I’m confused about how this works since it seems I’ve had some sort of coverage already.
2. Should I inform both insurance companies about my situation for coordination of benefits?
3. Can I choose which insurance to use as primary for doctor visits and prescriptions, or does it not matter?
From what I see, even with a higher deductible, my husband’s Anthem plan seems to offer better benefits.
4. Understanding insurance mathematics
I recently filled a prescription, and the copays were processed like this:
– Priority Insurance (primary): $15 copay
– Anthem Insurance (secondary): $11 copay
The pharmacy adjusted the total copay to $7. Was this handled correctly? With two private insurances, shouldn’t the prescription ideally be fully covered, leading to a $0 copay? Additionally, am I expected to pay an office visit copay for in-network doctors under both plans? My thought is that since I pay full premiums for both insurances, I should get full coverage collectively.
5. Do I need to run both insurances when filling a prescription?
My husband has a prescription for disposable insulin pumps that required prior authorization. Unfortunately, it took months due to communication issues between Corewell Health and Priority Insurance. Thankfully, Priority Health now fully covers his insulin pumps. However, does he need to file claims through Anthem for refills while the prior authorization is still valid? Anthem only became active on March 1, 2025, and had no involvement with that prior authorization.
I’m finding that there are many prescriptions that Priority won’t cover, but Anthem will. It feels like having both insurances could be a blessing and a curse. I initially signed up for dual coverage to address the challenges of prescription exclusions, as it seems each plan covers different medications. Any insights or advice would be greatly appreciated!
It sounds like you’re navigating a complex insurance situation, and it’s great that you’re asking these questions. Let’s break it down bit by bit.
How Do Deductibles Work?
When your insurance policy states that you need to meet your deductible before coverage kicks in, it means that you must pay that amount out-of-pocket for covered services before your insurance starts to pay. However, it’s important to understand that some services, like certain preventive care visits or specific prescriptions, may be covered before the deductible is met.
For your situation, if Priority Health is saying your family deductible has been met, it might be because they are counting specific expenses that qualify towards your deductible. Sometimes, the deductible includes certain costs that you might not be directly aware of, like coinsurance or other medical services.
Coordination of Benefits
Yes, it’s beneficial to notify both insurance companies about the coordination of benefits (COB). This process helps ensure that the claims are processed correctly between the two insurers. Typically, the insurance that you or your husband has through your employer would be considered primary, while the other would be secondary.
Choosing a Primary Insurance
While you typically cannot choose which insurance is primary and which is secondary—it’s determined by the order in which your insurance is set up—you can manage which one you present at doctor visits and pharmacies. It’s helpful to confirm with your doctors and pharmacies which insurance they recommend you use first.
Understanding Insurance Payments and Copays
Regarding your prescription example:
– When Priority Insurance processed the claim and resulted in a $15 copay as primary and Anthem resulted in a $11 copay as secondary, and the pharmacy combined it to $7, this typically means that the pharmacy applied the secondary insurance to reduce your payment.
– However, insurance coverage won’t necessarily cover the entire cost of the prescription just because you have two policies. In most cases, it’s not a straightforward “full coverage” for every scenario, and deductibles, copays, or coinsurance will still apply even with two insurances.
Office Visit Copays
Generally, you may still have to pay an office visit copay for in-network visits under both insurance plans. This would depend on the specific plans and agreements in place with the providers. You should consult the benefits summary for each plan to see how they each handle copayment structures, especially when coordinating care with two insurances.
Running Both Insurances
When filling a prescription, you typically run the primary insurance first, and if there are costs remaining after that, you can then run the secondary insurance to cover what’s left, depending on their policies. As for your husband’s prior authorization for insulin pumps, he should continue to use Priority Health until the authorization expires, as it won’t automatically switch to Anthem just because it became active. Once that authorization is up, you can start using Anthem.
Conclusion
Having dual insurance can complicate things but also potentially provide more comprehensive coverage. Don’t hesitate to reach out to each insurance provider’s customer support with specific questions; they can help clarify how each policy interacts. Keeping careful records of expenses and communications can help as you navigate this process.
Feel free to ask more questions if you need further clarification!