Need help with dual coverage: Aetna PPO & Kaiser HMO

I used to pay for my health insurance myself through the marketplace, and I had insurance from Kaiser Permanente. I started a job last year in May, and my employer offered Aetna PPO as insurance. I have many chronic illnesses, so I didn't want to completely stop using Kaiser, which I was paying for myself, until I found specialists with Aetna. Additionally, Kaiser wasn't managing my chronic migraines well. Therefore, I kept both insurances, which turned out to be a bad idea. I just realized this, and how primary and secondary insurances work is pretty new to me. I'm learning the hard way.

The fact is, I saw some specialists who are "out of network" for Kaiser and "in network" for Aetna last year. I canceled my Kaiser insurance, effective January 31, 2024. I saw this week on my EOB from Aetna that some claims for services from last year and January have been denied, and they are asking me to submit the claims to Kaiser first. What is strange is that they are referring to a couple of claims from the time I had both insurances and not all my visits. Aetna actually did process some claims from last year. I'm a bit confused.

Kaiser is an HMO, and most of the providers I have seen were out-of-network for Kaiser but in-network for Aetna. Some of them don't accept Kaiser at all. I'm no longer with Kaiser and checked my past coverage. It turns out that for out-of-network, my previous Kaiser plan doesn't cover anything. It is 100% coinsurance.

I have a couple of questions for which I would highly appreciate your insights. Since I'm no longer with Kaiser, can the provider still submit claims from last year when I was covered by them?

Aetna mentioned that they are not my primary insurance but the secondary. What are the rules to determine your primary insurance? I thought that since it is the insurance from my employer, it would be primary. Is it because I had Kaiser before Aetna that Kaiser is the primary? Sorry if this sounds stupid.

I'll get in touch with the provider and give them the information about my Kaiser coverage. In case they submit the claim and it is denied (which I think will likely happen), would Aetna pay the balance? I paid my copay at the time of each service when using Aetna. Or will I end up paying the whole bill?

Thank you very much.

submitted by /u/saitarg
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