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Coordination of benefits - Deductible

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graci

Junior Member
#1
State MD

I have a HMO plan with no deductible and my husband has a PPO plan with deductible of $600. If I go to a doctor who is in network for both. I understand that my primary insurance will kick in first and since I have no deductible, I will end up paying the co-pay of $25. I wanted to know if the doctor's bill is $200 and I pay a copay of $25, will the secondary insurance adjust the deductible? Would my deductible with my secondary insurance remain as $ 575 ($600 - $25 I have paid) or $400 ($600 - $200 charged by the provider)?

Thanks so much!!
 


#2
If this is a simple doctor visit I doubt the secondary will be involved at all. You will pay your co-pay and the HMO will pay the rest.
 

cbg

I'm a Northern Girl
#3
The answer to that question lies in the policies themselves. You would have to read the Coordination of Benefits section of the secondary insurance to see whether or not co-pays are applicable to the deductible. They might - they might not. It is a matter of the particular policy, not law.

However, in 40 years of administrating employee benefits, I have yet to see a policy where your deducible would be adjusted by the full $200 - after all, THEY didn't pay $200. That was paid by the primary carrier. It's possible that it might be adjusted by $25. It's more likely that it won't be adjusted at all. But it's exceedingly unlikely that it will be adjusted by $200. I wouldn't get my hopes up that it will work that way.
 

cbg

I'm a Northern Girl
#5
Is this taken from the secondary policy? If not, it is not binding on the insurance carrier but is a set of examples as to how things might work.
 
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