Whether it’s the traditional two-parent family or the more modern blended household, working couples are increasingly likely to have access to more than one health and dental plan.
The plans may differ in exactly what and how much they cover, but if you co-ordinate your benefits, you can take advantage of both and potentially get back 100% of your out-of-pocket healthcare expenses.
If both you and your spouse or partner pay group plan premiums, you may feel you can save money by going only with the plan with the “better” benefits or the lower premiums. But look through the two plans carefully before you decide. You might find that the second plan offers more in terms of orthodontic services, glasses or other benefits that you know you will need – enough to make it worth your while to belong to both plans.
Who pays your claim first?
The insurance industry in Canada has set up a special procedural guide so that all insurance companies are on the same page when it comes to which plan pays first and how benefits are calculated when you make a claim to more than one group plan.
Basically, if you are covered under your employer’s plan and also under your spouse’s plan, you submit your claim to your company’s plan first, and then claim for any balance through your spouse’s plan.
For example: Beth works at ABC Company while her husband, Aaron, works at 123 Corporation. Both have benefits plans but they differ slightly in what they cover and for how much. To stretch their dollars further and see if they can get back as much money as possible after visiting their dentist, physiotherapist or optician, Beth is also covered under Aaron’s plan as a spouse. Similarly, Aaron is covered under Beth’s plan.
Beth puts in her claim at ABC Company’s plan first; if it is not covered 100% by her plan, she can submit a claim for the balance through Aaron’s plan. Some drugstores and healthcare providers will automatically submit your claims to both plans, with no further action required by you. In other cases, once your plan has paid its portion, you will be required to submit your claim, along with the claim statement received from your plan, to the second plan yourself.
Claims for dependent children
Beth and Aaron have two dependent children who can also take advantage of their parents’ benefit plans. According to industry procedure, children are covered first under the parent with the earlier birthdate in the calendar year. Since Beth was born in April and Aaron was born in August, they would submit claims for their children to Beth’s plan first and Aaron’s plan second.
If children live with only one parent and both parents have benefits, the custodial parent’s plan pays first.
In cases of joint custody where both parents have benefit plans and their children are covered under both, the plan of the parent with the earlier birth date in the calendar year pays first.
There is also a definite priority for which plan pays first when it comes to more complicated, blended families. Contact your plan provider for further information.
How plans calculate benefits
The plan that pays first processes the claim as if there were only one plan. The second plan takes the payment by the first plan into account, and looks at the balance. If, for example, the first plan pays only 80% of the claim, the second plan may pay up to the remaining 20%.
You can only receive 100% of what you paid out originally – no more – but there may be times when the combined payments from the plans don’t totally cover what you paid out. For example, the combined coverage limits for orthodontics or eyeglasses may still be less than what you paid for them.
There are also some special rules where this hierarchy of payments does not apply, including benefits from auto insurance, out-of-country/province healthcare payments and Workers Compensation payments. Again, check with your plan provider for more information.