You and your Spouse Both Have Employee Benefits – How do we submit claims?

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If you and your spouse both have group employee benefits through your employer(s), it is often confusing to decide how to handle this.

Often times, one spouse waives health and dental coverage with their own employer’s plan knowing they have coverage with their spouses plan. However, many people don’t realize that you can ‘coordinate your benefits’ with both plans to maximize reimbursement on your claims.

Why would you want to coordinate your benefits?

  • Reduce your out-of-pocket expenses because you are being paid for claims under both plans.
  • Receive more comprehensive coverage than with your plan alone.
    • For Example: for orthodontics coverage (braces), the cost is often $6-8,000. If each of your plan only covers 50% up to a maximum of $3,000 lifetime, your family will be reimbursed up to a full $6,000.

Coordination Rules

Who submits when, if both spouses have coverage through their employer?

  • Each employee would first submit expenses through their own plan first, and then submit a copy of the receipts and a copy of the Explanation of Benefits document from the first carrier to the spouse’s carrier. Carriers will only reimburse up to 100% of the original cost of the claim(s).
  • For Dependent children, you must first submit their expenses through the parent’s plan whose birthday is first in the calendar year and then copies of receipts and the EOB to the other parent’s carrier. (e.g. The spouse with a February 24 birthdate would be first payor and the spouse with a July 7 birthdate would be 2nd payor.)
  • For blended families, it does get more complicated, but this is the order of submission.

– Birth parent who the child resides with more of the time is 1st payor.

– The other Birth parent’s plan is 2nd payor.

– The step parent’s plan who the child resides with more of the time is 3rd payor.

– And finally, if the claim hasn’t yet fully been covered to 100% of the cost it would go to the 2nd step parent.

 These are the parameters by which all group insurance carriers have agreed to.

If any questions, feel free to contact ENCOMPASS.

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