Can you explain the birthday rule with health insurance?

UPDATED: Jul 2, 2013

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UPDATED: Jul 2, 2013Fact Checked

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Asked July 2, 2013

1 Answer

It is not unusual for the health insurance plans of spouses to overlap, and insurance companies had to develop a method of deciding which coverage would be considered the primary coverage and which would be the secondary plan. According to the National Association of Insurance Commissioners, or NAIC, that solution was to allot the health plan with the earliest birthday in the calendar year as the primary account. The age of the policyholder is not considered, only the month and day of birth.

There are 2 ways that dual health insurance plans can be beneficial. First, the primary plan will pay for the covered amount of services under that plan, and then the second plan will pay any additional costs that the primary did not cover. Secondly, you can use dual health insurance plans to fill gaps in coverage. That way, treatment that is not covered by the primary plan will still be covered under the secondary plan. It will require researching the two plans and careful consideration of your current and future medical needs.

If both partners have the same birthday, then the primary plan, instead of being based on the policyholder's age, is based on the older of the two policies. In that situation, if you had been insured longer than your spouse, then your policy would be the primary, and your spouse's would be used to cover excess costs and fill gaps in the primary coverage.

Where divorce is concerned, the custodial parent is considered the one with the primary health plan, not the birthday rule. Similarly, court orders for children's health insurance outrank the birthday rule. Likewise, the birthday of a step parent does not preclude the birth parent from providing primary coverage. In this case, the parent provides insurance for their own dependent children, and the step parent provides secondary coverage. It is possible for both parents to be required to provide primary coverage for their own children, so that both policies fill a primary coverage role for different children.

Finally, the birthday rule does not apply across different types of health plans. Group plans pay first, regardless of whether the individual plan holder has the earlier birthday. If the individual plan offers the better coverage, you will need to make a decision of whether to include the child on the group plan at all.

Answered July 2, 2013 by Anonymous

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