What does eighty twenty coinsurance mean?
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.