If you have insurance through two current employers and the primary is an HMO can you decide to select a provider from the secondary PPO?
IMHO Yes CA Insurance Code 10270.98, but you would only get paid from the HMO
Group disability (Health Insurance) policies may provide, among other things, that the benefits payable there under are subject to reduction if the individual insured has any other coverage (other than individual policies or contracts) providing hospital, surgical or medical benefits, whether on an indemnity basis or a provision of service basis,
in such insured being eligible for more than 100 percent of the covered expenses.
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No. For one, in an HMO the providers are "capitated" paid part of the premium EVERY month, whether you use their services or not.
(HMO) Health Maintenance Organization - A health care payment and delivery system involving networks of doctors and healthcare institutions. It offers consumers a comprehensive range of benefits at one annual fee (often with co- payments or deductibles that vary from service to service) but they can… see only providers in the network. Physicians and other health professionals often are on salary or contract with the HMO to provide services. Patients are assigned to a primary care doctor or nurse as a "gatekeeper" who decides what health services are needed and when. (PPO) Preferred Provider Organization - A network of medical care providers that provides various medical care services to covered employees and retirees for specified fees. Although fees charged by PPO providers are usually less than those charged by non-PPO providers, the employee may seek treatment from any provider. A PPO allows you to visit a wider range of MD's on their list. Also you can visit NON-listed MD's and it will STILL pay, albeit a lower amount. (MORE)
Are health care providers obligated to accept payment from a secondary insurance at their fee schedule when the provider does not participate with the the patient's primary insurance?
Answer . \nIt has been my experience that providers of health care are not obligated to accept secondary or even primary insurnace coverages if they are not under contract with that insurance company. I believe they are free to accept no insurance coverage at all and demand "cash" up front if th…ey so desire. This would leave it your responsibility to sent the bill to your insurance(s) carrier(s) and get direct payment assuming they cover out of panel care. Some providers can not refuse you care even if you had no insurance but you would be responsible for the cost of care. (MORE)
If you are on two medical insurance plans and the primary will not pay for a prescription can the secondary be used to cover it?
Answer . Depends what the 2nd policy pays for. Doesn't hurt to send in the claim forms. Try reading the policy or brochure.
Secondary medical insurance is a second level of insurance coverage. Under most circumstances, the two policies are independent of each other. One policy may pay for a service while the other may not. The primary policy must pay first, then the secondary. The choice of which policy is primary or sec…ondary is established by a shared rule between insurance companies. It is not the policy holder's choice. Examples of Primary/Secondary coverage: A husband and wife both work and carry the medical insurance offered by their respective employers. The husband adds his wife to his policy. The wife adds her husband to her policy. Under most circumstances, the husband's plan would be his primary policy and his wife's plan would be his secondary policy. In like manner, the wife's plan would be her primary policy and her husband's plan would be her secondary policy. (MORE)
This is an important difference to understand. If your healthcare options include the choice between an HMO and a PPO, you will need to determine whether or not your trusted doctors participate and, if not, if you will be able to afford your share of their fee if you opt for a PPO. Some women feel t…he value of continuity, using a doctor they have seen for years, provides more secure diagnoses. In that case, you could pay for outside of network medical care. Be sure you know what each system offers so you can estimate your actual healthcare costs. A health maintenance organization (HMO) and a preferred provider organization (PPO) are both managed care plans. A managed care plan is a method of paying for and providing health care for a set fee using a network of hospitals, doctors, and other health-care professionals. The managed care plan monitors (and sometimes limits) the care that its doctors provide to members. Its goal is to ensure that unnecessary and expensive services to its members are minimized. HMOs are the most popular form of managed care. Here, all health services and financing go through one organization. Services include inpatient and outpatient care and prescription drug benefits. The HMO offers a network of hospitals and health-care professionals that its members must use. These health-care professionals are either employed by or under contract to the HMO. Members pay a monthly fee that does not change (unless, for example, the entire fee structure changes annually) regardless of the care they may need. Paper work for claiming the fee for the service is done by the provider (doctor) or by PCP. PPOs are far less restrictive than HMOs. A PPO consists of a group of hospitals and health-care professionals who agree to provide care to members at a reduced cost. A PPO is designed to provide affordable health care while maintaining flexibility for its members, who do not have to use the services within the network but are encouraged to do so. Staying within the network means that their costs are lower. If members go outside the network, they are still covered but must pay a higher deductible and contribute a higher co-payment. The policy holder has to claim from the insurance company for reimbursement. Apart from this there are other plans in PPO: . Beneficial Plans - Offers you a chance to waive deductibles, . Beneficial Rx Plan - Same as the Beneficial Plans in waiving deductibles, and also offers lowers costs on prescriptions. . Preferred Plan - You can choose the medical provider, plus the monthly bill you pay on this plan is quite reasonable. . Traditional Plan - You can choose your own medical provider and the rate on this is not costly . Plus Plan - You pay a reasonable rate here and get lower out-of-pocket expenses as well. . Health Savings Account - You pay a high deductible, but are exempted from tax on serious health expenses. (MORE)
Can the secondary insurance provider deny a claim that was not filed with the primary insurance provider first?
\n. \n Answer \n. \nLet me tell you what happend to me. I hope that this helps. I used to be covered by two insurance companies. My primary insurance company was through the company that I worked with. My secondary was with the company that my husband works with. When a claim was filed with… my secondary insurance company they wanted to know how much my primary insurance company paid for and until then they would not pay anything. So I had to submit to my primary insurance company and once they paid some then the secondary would. I hope that this helped:)\n. \n . \n Yes.\n. \nA claim must always be made with the primary insurer first. (MORE)
Not sure about the first one. A PPO is a Preferred Provider Organization. Usually, it works like this: The insurance company provides a list of health-care providers who are in its network. If you use one of them, you pay a nominal co-payment, much as you would with an HMO. The doctor agrees to ac…cept whatever the insurance company gives him (or her). If you go OUTSIDE the network, however, you will have to pay a co-insurance, usually a percentage of the doctor's fee, subject to deductibles. So, if you go outside the network and the doctor or lab charges you $1000 and you have a 20-percent co-insurance, you're going to pay $200, assuming you've already met your deductible. An HMO is a Health Maintenance Organization. When you go to the doctor, you pay a nominal co-payment. Your care is delivered within a group of connected providers, which is helpful if you are not able to keep track of various medications or condition (Medicare patients as an example). Typically, HMO is integrated and patient focused - PPO and other type networks can be fragmented where providers do not directly communicate with each other about the patient and care delivered. POS means Point of Service. It's just like going out of network in the PPO above. (MORE)
If the father is primary based on birthday and the mother is secondary is it legal for the mother to use her insurance as primary by not telling the provider about the father's insurance?
Answer . No, it's fraudulant. It's not practical, the secondary insurance should pay the remainder of the cost the primary insurance doesn't cover.
Are health care providers obligated to accept payment from a secondary insurance with whom they participate when the provider does not participate with the patient's primary insurance?
Yes they will have to accept payment from the secondary insurance, however they will have to bill the primary provider first.. What ever the primary insurance does not cover should be covered by the secondary insurance.. However, it will depend on the service being provided and the contracted amou…nt that each insurance has agreed to pay.. If the primary pays more than the secondary would have paid -there may be a refund due.. However, there may be co-pays and deductibles to be met with both insurance policies.. There could also be write downs--- you should only pay the lesser amount. the provider may have to take a loss if one insurance has a lower contracted amount (MORE)
If you have insurance with your employer and your spouse has insurance on you also which insurance is the primary?
If both you and your spouse have full medical coverage then the insurance compnay will revert back to your and your spouse's date of birth. Whoever's birthdate is first in a calendar year, then that is the primary insurance. For example, if your birthday is November 1, but your spouse's birthday is …February 12, then your spouses insurance is primary for both of you. (MORE)
Insurance . Your employer can refuse if they have good reason. I'm not certain what kind of reason that could be, but if they are providing insurance to everyone else except you, you might have a discrimination case on your hands.
The subscriber whose birthday comes first in the year is primary. The year is not considered. So a subscriber with a January 1 birthday is primary over the subscriber with a January 2 birthday. Hope this helps.
You could have two insurance companies pay the same medical bill or claim for a date of service through a process of subrogation where the first insurance company determined by the effective date of coverage will pay their portion of the bill and the second insurance company will pay the balance. Th…is process is called coordination of benefits. Secondary medical insurance is a second level of insurance coverage. Under most circumstances, the two policies are independent of each other. One policy may pay for a service while the other may not. The primary policy must pay first, then the secondary. The choice of which policy is primary or secondary is established by a shared rule between insurance companies. It is not the policy holder's choice. Examples of Primary/Secondary coverage: A husband and wife both work and carry the medical insurance offered by their respective employers. The husband adds his wife to his policy. The wife adds her husband to her policy. Under most circumstances, the husband's plan would be his primary policy and his wife's plan would be his secondary policy. In like manner, the wife's plan would be her primary policy and her husband's plan would be her secondary policy. Secondary insurance should not be confused with supplemental insurance. Supplemental policies usually abide by the primary insurance guidelines. If the primary allows the charge, the supplemental will allow the charge. Most supplemental policies cover the charges you would normally pay out of pocket. For example: A Medicare supplemental policy would cover the 20% coinsurance left over after Medicare pays 80% of the allowed amount. (MORE)
Yes, and you want them to because if they are paid out of order then it will be a mess to correct.
If mandatory insurance policy is provided through an employer and the insured dies shortly after termination of employment does the policy pay out?
It is going to depend on when the last premium payment was paid, if it was a portable product and how long it really had been after termination. This is because not all policies and companies are the same.
If I have primary insurance through my work and had secondary through my husband's work but he was laid off can I still use Cobra as a secondary insurance or is Cobra only if you have no insurance?
Cobra is available to those without insurance. Fortunately you have primary insurance and this would be useful.
When you have a primary and secondary insurance will the co-pay from your primary insurance be paid by the secondary insurance?
I have insurance paid for by my employer (primary) and through my husband's employer (secondary). In my experience, I have never had to pay the copay required by my primary because it is covered by my secondary. When I first got married, 2 years ago, I still paid the copay, but the doctor's office w…ould always send me a check for the copay a month later because the secondary paid it. (MORE)
Your insurance through your employer is your primary insurance, and your spouse's primary insurance is through his/her employer. If both husband and wife are insured on both insurance policies, then you have primary and secondary coverage. But you will still have to pay any deductibles and co-pays b…efore either policy will pay. The deductible is the amount you first have to pay (usually at the first of the year) before the insurance will pay anything. The co-pay is your percentage of what the insurance doesn't pay, which for many health insurance companies is 80% for them and 20% for you. There is sometimes a co-insurance that you have to pay also. Ex: Insurance companies have a set amount that they pay for any office visit, procedure, etc. If the bill is over what the insurance pays, then you are responsible for the balance. (MORE)
Preferred Provider Organization (also known as a PPO) is a managed care system that offers members health benefits and medical coverage based on a specific structure and network of medical professionals and facilities. PPOs are commonly sponsored by employers or insurance companies and help subsidiz…e member medical costs. All doctors, hospitals, and health care providers involved in the network are selected by the preferred provider Organization to provide medical assistance and health care coverage to its members. PPOs encourage members to utilize the doctors and hospitals within the PPO network but do allow members to visit out-of-network medical services providers. PPOs cover more of your medical costs if you visit an in-network provider. However, if a member visits a doctor or medical facility that is not within the PPO network, he/she is not covered at the level the member would be if he/she visited an in-network provider. But Health Maintenance Organization (also called an HMO) is one of three managed care health insurance systems in the United States. An HMO is designed to offer financial support and medical treatment to plan members. Some managed care systems don't offer medical treatment themselves. Rather, they offer different levels of financial coverage based on whether you visit in-network or out-of-network care providers. HMOs, on the other hand, have a system of physicians and hospitals that are involved in a specific coverage structure. If you're part of a Health maintenance Organization, you are only covered if you go to a physician within the HMO network. . (MORE)
If a husband and wife both have dental insurance through their employers, the employee's insurance is primary when the employee is the patient, and it must pay it's benefits. The spouse's insurance is secondary, and will only pay once the primary insurance has paid. Depending on how the policy is wr…itten, sometimes the secondary insurance will pay any residual fees up to the annual maximum. Sometimes the secondary insurance only pays if their fee schedule allows higher fees than the primary insurance. This assumes that each spouse is named as a dependent on each other's policy. Ask the insurance coordinator at your dental office to what benefits are available between the two policies. (MORE)
If secondary agreed upon insurance is lower than the primary insurance agreed upon price which one can the provider bill the paitent?
Primary has to process and pay claims first then secondary will process and pay leftover expenses according to their policy provisions. The secondary sometimes excludes payment towards a primary policy deductible.
Can an employee change health care plans HMO to PPO for example when the employer relocates the employee out of state and the plan like Kaiser is not available?
If the employer is the one that is relocating the employee to an area where they don't accept Kaiser's insurance, then I believe that you should be able to pay for your services/prescriptions upfront and then claiming it straight through the employer. You should check with your employer first, but t…hey SHOULD do it. If not, you're going to be out of luck UNLESS they will pay for your premiums on your new plan. Every employer is different. They are not required to provide insurance to you, so you just have to ask about their policy on that. (MORE)
Are either one of these health insurance companies any good Pacificare HMO and United Care PPO I need feedback from people who have or were ever covered by these insurance companies?
I have found PacifiCare to be less than helpful. On many occasions they deny receiving billing from providers. The providers refile only to be told it is too late. I have documentation proving this on at least 3 different providers. I am still waiting payments from November of 08. In November and De…cember of 08, when I used my card, I was often told there was no coverage. i paid for it myself. They have yet to remimburse me although the hospital has filed multiple times.. Currently I am on Anthem, which has paid every bill in a timely manner. Hopefully I will never be on Pacificare again.. Mary in Tulsa, OK (MORE)
The one that is better depends on your actual medical needs, and your desire for flexibility with the doctors that you see. In a HMO, you are restricted to a network of doctors, and typically there is no coverage if you go to an out of network doctor. In a PPO, you get more affordable coverage when …you stay in network but you can go out of network if you have to. You still have coverage out of network in a PPO, but you pay more before the insurance pays. For these reasons, HMO's are less expensive than PPO's. (MORE)
Can you have the same primary name on two health plans Not primary and secondary insurance coverage?
vehemately you can .but of your own disadvantage because you will be required to pay pramuim to different insurance company but will only be compaseted the actual amounth you need so doing that will be of no value
You have employer provided health insurance but want to put your child on another health insurance plan. Do not want to buy family coverage through employer insurance provider. Can you do that?
Sure. You are not "required" (at least not yet) to cover either yourself OR your dependents on your employer's plan at work. In fact, you can often get a more cost effective plan (i.e., cheaper or more "appropriate" for your actual needs) by going with an individual health plan for your dependents (…especially if you only have 1 or 2 kids to cover). Individual health plans, unlike most group/employer plans, are usually less costly because they don't have to insure everyone who applies for coverage. Therefore, under the right circumstances and assuming they don't have any "significant" health conditions, you should be able to save money. Here's a few tips: 1- Stay with "brand name" insurance companies, like Blue Cross, Aetna, Humana, etc. There are a lot of plans around that look good & cost less, but remember - you get what you pay for. You don't want to be "stuck holding the bag" because you tried to save a little money. 2- Consider a plan with a higher deductible ($2,500 - $5,000); you'll really lower the monthly cost (which is a "fixed" expense you have to pay) but still get the 2 benefits you'll use the most: doctor and drug copays (for example, $35/doctor visit and $15/generic Rx). 3- Find a local broker to help you. Go to http://nahu.org/consumers/findagent.cfm ; this is the professional association for agent who, like me, specialize in health insurance. 4- If you like, run some quote online yourself at sites like http://www.acforrest.com or http://www.norvax.com. This will give you an idea about what's available at what cost. Hope this helps a bit! (MORE)
HMO (Health Maintenance Organization) is one of three managed care health insurance systems in the United States. An HMO is designed to offer financial support and medical treatment to plan members. Some managed care systems don't offer medical treatment themselves. Rather, they offer different leve…ls of financial coverage based on whether you visit in-network or out-of-network care providers. HMOs, on the other hand, have a system of physicians and hospitals that are involved in a specific coverage structure. If you're part of a Health Maintenance Organization, you are only covered if you go to a physician within the HMO network. (MORE)
How does a company move to providing employer-based health insurance if they are currently just giving employees checks to buy their own health insurance?
Easy. Call a local broker or benefits company. It doesn't cost you anything and they can match you up with the best plan for you. If you want to do it yourself, call the carriers for a quote. You'll need to provide them with an employee census. Keep in mind you'll need to meet certain participation… requirements, usually around 70% of eligible employees will need to sign up for the coverage. The percentage varies by carrier and plan. In California you can visit http://tfp8.com/health-insurance.htm for more information. (MORE)
If a child has primary and secondary medical insurance who settles the dispute when the primary decides the secondary should now be primary instead of secondary as they had been for several years now?
It's not at the discretion of the insurance company as to who is the primary or the secondary. It is the sole decision of the policy holder(you). They are a paid service and are there to serve you.. Correction: . No, it's not at the discretion of the policy holder. The primary coverage is based on… who's birthday comes first. For example, in this particular case, the child lives with his mother and stepfather, and the stepfather and the biological father both have him on their medical insurance policies. The father's birthday is in October and the stepfather's birthday is in December. So the father's insurance is primary, and the stepfather's insurance is secondary. These are the quidelines insurance companies use to determine which one is primary, and which one is secondary. (MORE)
As a provider i file primary insurance. do I have to also file secondary insurance after primary pays?
You should or you customer WILL be PISSED for having to do the leg work of getting the information of what the primary paid and getting it to their secondary.
Medicare is primary if your group is under 20 lives. 20 lives ormore and medicare is secondary to your employer paid group plan.
yes, they will treat it as if the primary was a different company. You pay two premiums. If they do not, contact the DOI.
You have an hmo insurance plan in Virginia your husband spends a lot of time in New York and is not covered by your hmo if you switch to a ppo will he be covered in N.Y. and if he is will it cost more?
Yes and Yes. . An HMO provides coverage for in-network providers only and a PPO plan will cover both in and out-of-network providers. That is the main difference between the plans. . However PPO rates are typically higher than HMO rates. . Also if using an out-of-network provider, reimbursement… is almost always based on a deductible/coinsurance arrangement with the plan typically paying either 70% or 80% of the bill after the deductible has been paid by you. (MORE)
Is it required to make a primary dental insurance adjustment if the dentist is a preferred provider before submitting a claim to secondary insurance?
You wait until both claims are received then write off the lesser of the two amounts
If you mean that you are covered under both types of policies and want to know whether you will receive benefits under both, you should know that each state has laws related to "coordination of benefits" which dictate which policy will pay 1st and which one pays some portion of any remaining cost. …There is a national standard set by the National Association of Insurance Commissioners that most states follow. The Coordination of Benefits standards 1st determine what coverage is primary. If you are employed, this is usually the coverage where you are the policyholder. The secondary coverage would be the one where you are a dependant--like your spouse's coverage. After that is determined, it is the dentist's contractual relationship with the patient's primary plan that determines the amount that can be collected from the patient and what is paid by the carrier. So, if the DHMO is primary, then the patient only pays the co-payments and some of that may be reimbursed by the secondary DPPO. If the primary carrier is the DPPO, then the DPPO pays the contracted portion of the fee to the dentist and the patient has the coinsurance amount--usually 20% for basic care and 50% for major procedures. The DHMO, as secondary carrier, would not pay any portion as their plan is superceded by the contractual relationship of the DPPO. (MORE)
When a DPPO is primary coverage, the charges paid by the patient are based on the agreed DPPO discounted fees--not the DHMO schedule of charges. The dentist would bill the DPPO for the procedures performed. If the dentist is in the DHMO network, he or she would also get his or her regular capitation… payment for that patient. (MORE)
If a person has two Medical insurances and the primary denies due to preexisting will the secondary pay?
It depends on a few things. If your primary insurance is say less than 2 years old, they can deny claims to determine whether the condition is pre-existing. If you have had the secondary policy longer/ or the pre-x period has already been satisfied, then they may pay the claim as secondary. As long …as the treatment is indicated as covered benefits in the policy. These cases are common when both spouses have covered each other on their jobs. And/or when a child is covered under both parents policies. There could be a coordination of coverage issue with the latter. (MORE)
If you have health coverage through two different companies the one through retirement and one through current employer who is primary?
Both of you policies will spell out this in the "Co-ordination ofBenefits" clause. Most likely the oldest plan will be primary butsome go by the birthday of the person insured under the policy. Ifthe retirement benefit coverage is from your spouses policy and thecurrent employer is in your name the …birthday may come into effect.Check the COB clause and you will probably find out. If not callthe companies. (MORE)
A step-up transformer has 300 turns on its primary coil and 90000 turns on its secondary coil If the current is flowing through the secondary is 5 amps what is the current flowing in the primary?
150 amperes Answer Your transformer's primary current will be: I s = I p ( N s / N p ) = 5 (90 000/300) = 5 x 300 = 1500 A
Hotels and restaurants are examples of primary providers in thehospitality industry. Secondary providers include conferencecenters and nightclubs.
No. Not if the employer is not set up to offer it to any of his/her employees OR if the company does offer it and you are a 'Part-time employee' working under 35 hours a week OR if you are a 'Full-time employee' and have not worked for the company for 90 days.
It is usually written in an insurance policy if the policy is primary or secondary. If both policies have language that makes them secondary if other insurance is present then they may split the amount owed. State laws may change this.
For the most part, no. An HMO is a type of managed care plan that focuses upon keeping the member healthy. It is a genre of "managed care", of which there are several models. The models differ mostly in the amount of choice that the member is given in using physicians of his/her choice, at least …without first getting a referral from the member's "primary care physician". The primary care physician is a provider under the HMO and assumes the main responsibility for the patient's care, and, as necessary, referrals to specialists. Because the HMO "manages" the care, the care is kept in a fairly tight sphere, thereby lowering overall costs. Therefore, participation by a member in an HMO is usually amoing the more economical health care options. Although HMOs are not technically "insurance", they are generally regulated by state insurance regulators. The insurance regulator is concerned with the HMO's financial stability, reasonableness and sufficiency of rates, and similar factors/ (MORE)
We have Medicare and added on Anthem. Does that mean Medicare is primary (Paying 80 percent) , and Anthem is secondary?
Employers only have to provide health insurance if they meet certain legal requirements. A business must have a certain number of full-time employees for it to be required to provide insurance for health coverage.
"It's all about preference. Each type of insurance has its own benefits. It is better to stick with the one that meets your needs the most. Also, make sure to pick that one that you can afford."
The major difference between HMO and PPO is the fact that HMO lets individuals choose doctors within a specific network, while PPO allows patients to choose their own health care provider.
Can you have a hmo and a ppo plan at the same time more specifically kaiser hmo through my employer and aetna ppo through my spouse's?
Technically yes, each of you will have your own primary plan andall claims for each will go through that plan first, but assecondary, the other plan will cover in areas where the hmo doesnot with provisions, each plan is different that way, but usuallyit gives more options for health care where to h…mo is restrictive,you just have a lot more hoops to jump through. (MORE)
PPO and HMO, both are acceptable dental insurance. PPO dental insurance allows you to concern other dentist with some limitation coverage. HMO dental insurance provides expert dentist in their network to offer best treatment. You can choose any insurance plan which suits you the best.