VEHI Employees with Other Coverage Options
How to Reconcile Order of Payment Errors Involving “Other Carriers”

Some employees in a VEHI health plan have other health insurance coverage as well.  It could be through a spouse’s benefit plan or a government plan like Medicare, Medicaid or Tricare.  (To keep things simple here, we will refer to additional sources of non-VEHI coverage as “other carriers.”)

Coverage through “other carriers” for VEHI subscribers begs three questions:

• Who pays first generally? (primary vs secondary)
• What is the order of payment if the VEHI plan is primary and integrated with a Health Reimbursement Arrangement (HRA)?
• How do you clean up order of payment errors with providers that involve other carriers?

Guidelines on the order of coverage and claims payments:

• The VEHI plan is the primary-payer in most instances.
• An HRA is part of a VEHI health plan; therefore, if the VEHI plan is primary, the HRA must pay directly in tandem with the VEHI plan, and before other carriers contribute.
• If an employee has dual coverage through a spouse, the employee has primary coverage with VEHI and his/her spouse has primary coverage through the spouse’s employer plan. There are rules to determine which coverage is primary for the children, and that will be coordinated by BCBSVT on behalf of VEHI and the spouse’s insurance carrier.  (See yourBenefit Description Document for details.)
• Generally speaking, Medicare will be secondary for all benefit-eligible active employees and their dependents on the VEHI plans.
  • This means the VEHI plan will pay first, followed by the HRA.  Any balance owed will be sent by a provider to Medicare for payment.
  • In rare instances, Medicare could be the primary payer, before the VEHI plan and the HRA contribute.
• Medicaid and Tricare are always the payer of last resort.
  • The VEHI plan will pay first, followed by the HRA. Any balance owed will be billed by the provider to Medicaid or Tricare.

Occasionally, even when all parties are processing claims and issuing reimbursements in a timely manner, other carriers may pay for a claim when it was not their responsibility. Carriers regularly audit accounts to identify these situations and to reconcile reimbursements.

Reimbursement and Reconciliation Challenges Arising from the Future Planning Situation

Because of delayed payments by Future Planning Associates, many doctors and other providers never received the payments due them from employees’ HRAs, and so they billed other carriers (like Medicare, Medicaid, etc.).  The other carrier paid these claims.  As a result, some employees are now being sent HRA funds for claims other carriers already paid.

Example: A school employee incurs a claim for $1,000. The VEHI Gold CDHP applies the claim toward the deductible, and the district’s HRA is responsible for some or all of that amount. But the provider, because payment was delayed, bills Medicaid instead, and Medicaid pays the entire $1,000 amount to the provider.  Additionally, the employee receives a reimbursement from their HRA for the same service, even though she never paid for the service because Medicaid did.

What should an employee do in a situation like the one above?

1. Employees are not entitled to keep HRA funds they received for claims other carriers paid prior to the employee receiving the funds.
2. An employee, therefore, who receives HRA funds she is not entitled to should immediately pay the claim amount to her provider with the HRA funds as originally intended.
3. When making the claim payment in step two, an employee should direct IN WRITINGthat the provider (a) reverse the claim to the other carrier (e.g., Cigna, Medicaid, Medicare, etc.) and (b) reimburse the other carrier with the HRA funds received from the employee.
4. Employees should maintain a record of payment and correspondence with their providers.

Providers, again, are familiar with this process, which occurs on occasion even when HRA administrators are processing funds in an accurate and timely way.  As mentioned earlier, carriers will audit accounts to look for other sources of responsibility and, if warranted, seek to recover funds that were paid to employees in error.