View Full Version : Deductible, Copay, and Coinsurance - which first?

08-12-2003, 09:35 AM
I have a $100 deductible, a $20 copay, and coinsurance of 80%.

The charge for my medical service is $115.

I know the deductible applies before the coinsurance. Where does the copay come in?


08-12-2003, 09:44 AM
Generally, the co-pay would apply for certain specified services, such as physician office visits, and the deductible/coinsurance would apply for all other services.

If on the co-pay list: You pay $20, plan pays $95

If not on the copay list: You pay $100 + .20*15, plan pays $12, assuming you have had no other services that have applied to your deductible.

There are lots and lots of variations though, so I would have to know the details of your plan to be sure.

Dr T Non-Fan
08-12-2003, 02:16 PM
I agree with Mainy-chick. Copay services are usually exempt from the deductible. Otherwise this very situation will invariably come up.
You should also check your customer service people. We can only theorize.

Kitty Cat
08-15-2003, 12:14 AM
Yep I agree w/ you both, copay is exempt from deductible. So when you are reading a benefit line there is either a copay or a % of coinsurance. If there is a coinsurance, then the mbr has to meet the deductible first before the insurance pays anything, but not the case for copay. Basicly, for copay benefits, the insurance company pays the rest before you meets the deductible.
actually, then I have a question. Does a mbr need to pay any copay, once one meets the OOPM (out of pocket maximum)? I think one still needs to pay the copay. what do you think? thx!

Polly Nomial
08-15-2003, 09:16 AM
Iit's rare to have both a copay and coinsurance apply to the same benefit but new products are being sold as fast as someone can figure out a new configuration of pay schemes.

In general, copays are paid first and always. They do not apply to the out-of-pocket max. Of the remaining cost, the deductible is applied and then the coinsurance.

Drugs are generally administered separately. Copays apply until a separate (though rare) o-o-pocket max.

But once again, new combinations are being dreamed up as we speak. You need to read the policy.

08-15-2003, 12:11 PM
My company offers some copay/deductible combination plans. Any benefit which is offered with a copay requires that the copay be paid, even if the annual out-of-pocket max has been met.

08-15-2003, 12:28 PM
i think i saw a pharmacy plan once where there was a deductible, then a copay and then a coinsurance if the drug were more expensive than the formulary equivalent

I guess some product design people never learned the kiss principle, hey I need to add that to the acronym thread

Kitty Cat
08-16-2003, 03:24 PM
yep, actually I saw that kinda of benefit line before, deductible, copay and coninsurance %. That kind of plan is really sucks. I think it's a catastrophic (not sure the spelling, sorry) plan. The premium is relative cheap, but once if there is anything happen then the customer will become really mad at the insurance company because they need to pay so much. We they need to read their EOC! Take some time to learn about your plan, otherwise you don't know what you are insured.

11-21-2003, 11:59 AM
I have insurance with a $500 deductible and 20% coinsurance, and my husband has insurance with $500 ind. deductible and $1500 family deductible. If my first claim is for $800 for a medical procedure on me, I must absorb the $500 deductible, and 20% of the $300 for a total of $560.

My question is, if I turn this in to my husband's insurance, what will they pay. Do they apply the $500 deductible for me? I thought that one of the benefits of having dual insurance is that the second one pays whatever the first one did not pay.

11-21-2003, 12:21 PM
But both are subject to their own deductibles, coinsurances.

I believe, in your scenario:

The primary sees the $800 charge. $500 deductible applies, $300 remains. They pay 80% or $240, you are responsible for $560.

This $560 rolls to secondary carrier. $500 deductible applies. They pay 80% of the $60, or $48, and your responsibility falls from $560 to $512.

The main advantage would be for claims after the deductibles were met (2nd carrier pays 80% of your 20%), situations where the 2nd carrier has a lower deductible, and the fact that it will apply to your family OOP max on the secondary plan, which will be helpful if multiple family members have claims.

Dr T Non-Fan
11-21-2003, 12:23 PM
5again, I am not a claims examiner or processor, and COB is pretty confusing.

That said, I think:
You will file a claim with your hub's insurance for $560 (the amount you pay on the claim through your own insurance). Your husband's insurance should apply $500 toward your deductible, then it will reimburse you 80% of the $60 left over.

Lots of companies are simply refusing to allow double-insuring, just to rid themselves of COB issues. COB is high maintenance.

11-21-2003, 12:50 PM
I don't like to double insure either, but his company insists I get my own through work if possible. Then they still cover me as a secondary policy. I used to double insure for years voluntarily, and then decided it wasn't worth it and dropped my coverage. He has no option to drop, since it is a union benefit. He has to carry their insurance and it is a family plan only. They make it so confusing.

One other reason to double insure is that sometimes you must carry insurance for 10 years or so in order to be able to continue it when you retire.

One other reason is that for second (and third, etc) marriages, there is a possibility the marriage will not last, and you may have to scramble to be covered. Cobra works for a few years, but you need your own insurance eventually.

I would drop mine in a minute if they would let me. My drugs cost more now, and I am out the $1,500 that I have to pay, and I had no major health inssues so the secondary company didn't have to pay anything.