Spouses may elect to maintain separate health care coverage from their employers.
In a society where a husband and wife often work outside the home, situations where both spouses have their own employee-sponsored health insurance are not uncommon. In many cases, this can work to a family's advantage by providing access to additional coverage if needed. Certain procedures exist to determine which policy will provide primary coverage and to avoid a duplication in benefits.
Primary Coverages
In most cases, when spouses have separate health insurance coverage from an employer, their own policy will provide primary coverage. For instance, if a spouse needs coverage for a medical condition, he needs to file the claim through the policy offered by his own employer instead of his wife's company; however, if the claim is denied, the husband can consider obtaining coverage by filing a claim under his policy. He may also pursue additional coverage under his wife's policy if he a claim exceeds his policy coverage amounts.
Coordination of Benefits
In many cases, an individual's health coverage at work extends coverage to her dependents, including her spouse who may also have his own coverage for himself and his dependents. To avoid duplication of coverage in these situations, group health insurance plans typically include a provision known as "coordination of benefits." Each spouse's own policy will provide primary coverage, with the other spouse's policy providing excess coverage in accordance with the coordination of benefits provision.
Birthday Rule
Complications may arise when a couple's children are listed as dependents on the policies of both spouses. To resolve this issue, the so-called "birthday rule" was established. In essence, this rule states that primary coverage for the children is provided by the policy of the parent whose birthday comes first in the calendar year. The other spouse's policy is used to provide excess coverage or fill coverage gaps if necessary.
Considerations
While coordination of benefits provisions allow families to maximize their health insurance coverage, the intent is not for people to profit from health insurance. Coordination of benefits ensures that duplication of coverage will not occur so couples are not paid twice for the same event. Instead, families may have access to additional benefits that may not be available through the primary policy, which can help keep health care costs to a minimum.
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