How to Determine Primary Health Insurance Coverage

The determination of primary health insurance coverage is important for claims payment. If you have coverage from more than one source, most health plans and providers follow the rules established by the National Association of Insurance Commissioners to determine how to apply benefits and pay claims. The NAIC has rules to determine your primary and secondary health insurance plans. Benefits and claims are always applied to the primary plan first. Any secondary coverage may cover what the primary plan does not.

Instructions

• 1

  Look at your health insurance ID card to determine if you are a dependent or non-dependent on your health plan, as indicated on the card. The primary plan is the one where you are a non-dependent. For example, if you are covered through your employer's plan, you are a non-dependent and that plan is primary. If you are covered through your spouse's plan, you are a dependent on his plan. This is the first rule in determining the order of plans.

• 2

  Review your active status with your employer. The health insurance you receive as an active employee is primary to any other coverage you may have. Post-employment coverage, such as retiree benefits, is primary unless you get another job with benefits and pick up coverage. Then, the retiree plan is secondary to your current employer's coverage.

• 3

  Evaluate you and your spouse's birth dates to determine if your health insurance or your spouse's insurance is primary for your children. Whichever parent has an earlier birth month and day (year excluded) is the parent who provides primary coverage to your children. If you have the same birthday, the parent who has been in the plan longer becomes the parent providing primary coverage.

• 4

  Review your legal separation agreement or divorce decree to see which parent is to provide primary health insurance coverage to your children. Usually, it's the parent that the court establishes as more financially responsible. The other parent may provide the child's secondary coverage and if remarried, his spouse's plan may provide a third level of coverage.

• 5

  Review your health insurance plans' paperwork and if you have a non-Medicaid or Medicare plan, that plan is typically your primary coverage. Any employer-sponsored health insurance is primary to any state or federally sponsored health insurance.