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What is the difference between copay and coinsurance when you have primary and secondary insurance?


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2008-06-30 14:42:08
2008-06-30 14:42:08

A copay is a "set" dollar amount you pay at the time of treatment. For instance, a $35 doctor copay. If you have level one doctor visits, you pay nothing more than the $35 doctor copay. Co-insurance is the percentage you share with the insurance company after your deductible has been met. When you have two policies - your primary insurance will pay first (subject to deductible and co-insurance), and then your second policy starts with the balance left from the primary policy (subject to deductible and co-insurance again). For instance a primary policy with a 5,000 deductible and 80/20 co-insurance of $5000. Your bill for surgery is 6000. You pay 5,000 + 20% of $5000 (1000) = $6000.00 Your balance of your surgery bill is 0

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There is one major difference between these types of claims. When a person has two different insurance carriers, one of them is designated as the primary coverage and the other as the secondary. The primary insurance should be billed first and normally pays the bulk of the bill. The secondary insurance gets billed for the remainder of the bill which the primary insurance did not pay for.

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Eighty twenty coinsurance is usually expressed 80/20 by insurance companies. The first number (80) represents the percentage of payment an insurance company will pay for a service and the second number (20) is the percentage the person receiving the service is required to pay. Other popular coinsurance amounts are 70/30, 60/40, 50/50. It is important to note a couple of factors in determining when an insurance company will pay coinsurance. First, an insurance company will only pay 80% on what the insurance considers the "allowed" amount of a fee. Generally insurance companies have fee schedules which designate the maximum amount they will pay on any particular service. This allowed amount could be more or less than the fee that is charged for the service (usually the allowed amount is lower than the fee). Second, an insurance company will only pay 80% for services rendered after the insured has satisified their deductible. Therefore, if your insurance policy has a deductible of $500, the insured must pay out $500 towards their claims then insurance companies will consider paying 80% coinsurance on the remaining balance of unpaid services. Coinsurance does not apply to deductible amounts. Third, the service that is rendered must be a covered service under the insurance policy. If the service is not a covered service most insurance policies will not pay for the service, and usually it does not apply towards the deductible either. Lastly, if the provider of the service does not have a contract with your insurance company, the insured will most likely owe the difference between the allowed amount of the insurance company and the billed amount from the provider. Coinsurance does not apply to the portion of the fee that exceeds the insurance companies allowed amount. Billing the insured for this difference is referred to as balance billing.

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