Most health plans are written so that plan members share in the cost of healthcare.
For example, an 80/20 plan means that a carrier will pay 80% of the covered charges leaving the patient to pay the remaining 20%.
Some patients have access to a second or even a third (tertiary) health plan that helps to offset some of the patient's share of costs.
This additional coverage may be available because:
When a patient has more than one plan, all health plans will be billed and all payments will be applied to that date of service. In spite of how the clam is calculated no more than 100% of the billed charge will be paid.
The process for billing more than one carrier
Example of primary/secondary processing
Ben J. has an 80/20 plan through his place of employment and his wife, Janis J, also covers him under an 80/20 plan through her company. Neither plan has a deductible.
Ben goes to the doctor and incurs $500.00 in healthcare costs.
The same claim is billed to Janis’ plan with the EOB showing the $400.00 payment.
Although Janis’s plan could pay out $400.00 they know (because the EOB tells all) that the bill was only $500.00 and that $400.00 has already been paid by the primary carrier - they issue a payment for $100.00
Between the two carriers the claim has been paid in full with ZERO out of pocket from the patient.
Keep in mind that secondary (tertiary) reimbursement is subject to the provisions under each plan and the allowed amounts. Depending on the processing guidelines 100% may not always be forthcoming.