How Secondary Insurance Works with Kaiser Permanente

Having multiple health insurance plans can provide more complete coverage, but it also requires coordinating benefits between your different plans. So how does secondary insurance work if you have Kaiser Permanente and another health plan?

Secondary insurance kicks in after your primary coverage pays. The coordination process aims to maximize your total reimbursement while preventing double-dipping between plans.

Below we’ll explain the key things to know about using Kaiser Permanente as either your primary or secondary insurance.

Overview of Secondary Insurance with Kaiser

Here are some high-level points on how secondary insurance works with Kaiser Permanente:

• The primary plan pays first, up to its benefit limits.

• The secondary plan pays next, covering leftover costs up to its own limits.

• Kaiser applies its normal coverage rules and requirements regardless of primary/secondary status.

• Members must follow Kaiser’s authorization protocols even if it’s the secondary insurer.

• Kaiser coordinates benefits to prevent overpayment while giving members full coverage.

So in essence, the secondary plan supplements the primary payer, providing additional coverage and financial protection.

How Kaiser Permanente Handles Coordination of Benefits

Kaiser puts effort into smoothly coordinating benefits when members have multiple health plans. Here are some key aspects of Kaiser’s coordination process:

• Following state regulations – Kaiser complies with regulations for coordinating benefits across carriers.

• Identifying the primary payer – Kaiser determines which plan is primary based on rules established in state law.

• Paying secondary claims – If Kaiser is secondary, it pays supplemental amounts after the primary plan’s payment.

• Applying normal coverage rules – Regardless of primary/secondary status, Kaiser’s regular coverage criteria and requirements apply.

• Preventing overpayments – By coordinating, Kaiser aims to prevent total payments from exceeding billed charges.

• Streamlining for members – Kaiser tries to make having multiple plans seamless and advantageous for members.

So Kaiser applies standardized processes to handle coordination of benefits efficiently and appropriately.

When Kaiser Permanente is the Primary Insurer

If Kaiser is your primary health coverage, things operate as usual:

• You get care from Kaiser doctors and facilities.

• Kaiser handles authorizations for services and prescription drugs.

• You pay Kaiser’s standard deductibles, copays, and coinsurance.

• Kaiser bills and reimburses providers under its contracted rates.

Having secondary insurance doesn’t change much when Kaiser is primary. The secondary plan may provide additional payouts after Kaiser’s payment.

Key Perks

• Access to Kaiser’s comprehensive network and benefits

• Kaiser handles all prior authorizations

• Coverage according to your Kaiser plan details

• Secondary insurer can cover additional costs

When Kaiser Permanente is the Secondary Insurer

Things work a bit differently when Kaiser is your secondary coverage:

• Your primary insurer takes the lead on providing benefits.

• You must comply with Kaiser authorization rules even if it’s not the primary payer.

• The primary plan’s payment is deducted from Kaiser’s allowed amounts.

• You typically need to submit your EOB from the primary insurer to Kaiser for reimbursement.

Key Notes

• Get care from Kaiser doctors if possible.

• Remember Kaiser’s requirements and network rules.

• You’ll likely need to file claims rather than direct billing.

• Kaiser payment will depend on primary plan’s reimbursement.

So being secondary has some administrative and financial impacts but still enhances your overall coverage.

Submitting Claims When Kaiser is Secondary

Here’s how billing and claims submission usually works when Kaiser is your secondary insurance:

• You get care from a provider covered by your primary plan.

• That provider bills your primary insurer first.

• After the primary plan processes the claim, you get an Explanation of Benefits (EOB).

• You submit the EOB to Kaiser for supplemental payment of any leftover charges.

• Kaiser pays secondary amounts according to your plan details.

• You may need to pay any remaining costs not covered by the insurers.

This involves more steps for you but lets Kaiser coordinate payment.

How Payment Works as the Secondary Insurer

When paying secondary claims, Kaiser offsets its allowable charge by the primary plan’s payment. For example:

• Provider’s billed charge: $1,000
• Kaiser’s allowed amount: $800
• Primary payment: $500
• Kaiser secondary payment: $300
• You owe: $200

So Kaiser aims to fill the gap between the primary payment and its allowed charge. This prevents overpayment but gives you maximum combined coverage.

Waiving Certain Rules as Secondary Insurer

In some cases as the secondary payer, Kaiser may waive certain requirements if the primary insurer has already authorized services:

• May cover out-of-network care approved by primary plan

• Could waive service authorization rules

• Often waives primary care provider referrals

• May relax limits on number of covered visits

But Kaiser will only do this selectively based on the circumstances. You should always confirm with Kaiser before obtaining care not normally covered.

Key Factors That Determine Primary vs. Secondary

Which insurer is primary vs. secondary depends on certain order of operations rules documented in state regulations:

• The plan covering you as the policyholder (not a dependent) is primary.

• For dependents, the parent’s plan whose birthday is earlier in the year is primary.

• If you’re a dependent child and parents are divorced, the parent with custody is primary.

• The plan covering you as an active employee is primary over a retiree plan.

• For an eligible child covered under two plans, the plan of the parent whose birthday falls later in the year is primary.

So Kaiser determines primary vs secondary status methodically based on standardized hierarchies.

Coordinating with Medicare

For seniors with Medicare and Kaiser coverage, here’s how coordination of benefits typically works:

• Medicare Parts A and B are primary.

• Kaiser plans are usually secondary to Medicare.

• You must use providers who accept Medicare assignment.

• You pay Kaiser copays and coinsurance after Medicare payment.

• Kaiser can cover some costs Medicare doesn’t pay.

Make sure you understand all rules for using your Kaiser plan with Medicare as either primary or secondary.

Member Responsibilities for Coordinating Benefits

To make coordination of benefits work smoothly, members have certain responsibilities:

• Understand your plan details and coverage rules.

• Inform all your providers about your multiple health plans.

• Get required authorizations from each insurer.

• Follow each insurer’s claim filing procedures.

• Provide supporting information like EOBs.

• Pay cost shares owed to providers.

• Notify plans if other insurance changes.

You play a key role in coordinating your benefits effectively.

The Takeaway

Using Kaiser Permanente along with a second health plan involves some extra steps but can maximize your total coverage. Just remember whether Kaiser is your primary or secondary when going for care and submitting claims. With proper coordination, your multiple plans can work together to provide greater healthcare value and financial protection.