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Covered California Q&A

Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.


Double Coverage: Who Pays First?

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Question: I have an individual health insurance policy paid for by my employer. I also have the benefit of being on my husband’s health insurance through his employer. I always thought that MY coverage was primary over the coverage provided by my spouse’s employer. But my carrier said group policies are always primary over individual policies. Is this true? (South Carolina).

Answer: Coordination of Benefit Rules were codified by the National Association of Insurance Commissioner in 1986 and each state uses this model with some modifications. The rules cover how the primary payer is determined when an insured employee or dependent has double coverage. For example the rules state that the group plan covering the insured as an employee pays first. To determine who pays first on dependent children’s claims, the plan covering the parent whose birthday is earlier in the calendar year is primary.

The Coordination of Benefits endorsement on group health policies does not apply to individual health insurance policies so they generally pay their full benefits regardless of other group health policies in force. But there are variations between states, it is important that you review the provisions of your individual health insurance policy because they will sometimes include their own provisions about other insurance.

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