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Coordination of benefits - Deductible

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Junior Member
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!!

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.


I'm a Northern Girl
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.


I'm a Northern Girl
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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