Claims straddling two different plans

[Fielding Mellish]

A health plan terminated effective Dec. 31 and its members all joined a new health plan on January 1. A participant went into the hospital on December 30 and was discharged on January 2. What plan is responsible for those charges? And why?

Thank you.

[GBurns]

It depends on the terms of the contract. Sometimes, it is the old plan that has responsibility for completing the treatment episode, sometimes there is a "phase out" period and sometimes it is the date of efffectiveness of the plan. This date of effectiveness is negotiated.

[leevena]

Not enough info available. In a fully-insured program GBurns is correct, there is usually an episode of care process in place. (I say usually because I am not versed in all states regulations). In a self-funded program it depends on how the contracts are written (12/12, 12/15, run-in, etc.) as to who has the liability. In fact, it is possible that the employer could be left with the costs.