Insurance Basics: Deductible & Coinsurance

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PostPosted: Wed May 02, 2012 12:47 pm   Post subject:   

Quote:
I have an office visit appointment tomorrow (the cost is $100).


You don't tell us whether your insurance coverage is an HMO or PPO or some other form of health insurance.



You mention a $350 deductible and then use an incorrect term to describe an 80/20 coverage arrangement (you call it "copayment", but 80/20 coverage is known as "coinsurance").



If you have a deductible, the policy may or may not treat copayments as a deductible expense (the $100 office visit fee may be the copayment amount, although that would be unusually high -- most copayments are somewhere between $20 and $40).



If you can tell us what type of health insurance you have, we can probably give you a better answer. If you prefer to keep that more confidential, send me an email by clicking the link below.


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PostPosted: Wed May 02, 2012 12:54 pm   Post subject:   

Quote:
When does the coinsurance come into play?


Coinsurance is the percentage of sharing covered expenses between the insurance company and the insured. It normally applies AFTER the deductible has been satisfied. So if you have a $500 deductible and 70/30 coinsurance, you would probably have to pay the first $500 of annual medical expenses 100%, and after that, you would pay about 30% of your covered expenses.



Obamacare is changing the way "preventive" health care is paid for. By 1-1-2014, as the law currently exists, no one in America who has health insurance will have an out of pocket expense for "preventive" heatlh care (annual check up, well-baby / well-child appointments), whether there are deductibles or copays or coinsurance in the coverage. That may already be true in some policies today.


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PostPosted: Thu May 17, 2012 5:44 pm   Post subject: Deductible  

Hi Sil,



Please explain exact meaning of "NOt Subject to Deductible.

Thanks.


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PostPosted: Tue Sep 11, 2012 4:01 pm   Post subject: copay  

Lets say someone has a policy that pays 80 percent copay is 20% deductible 50$. Lets say that an office sells an in office insurance policy or discount plan for 50$ a calender year that gives a 20% discount on all procedures. does that give the office the right to waive the 20% copay from the patient insurance?

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PostPosted: Tue Sep 11, 2012 10:16 pm   Post subject:   

Quote:
someone has a policy that pays 80 percent copay is 20% deductible 50$


This statement makes no sense as written, therefore your question also makes no sense.



Deductibles and copays are not the same thing. Copays are measured in dollars, not percents, and deductibles are stated as dollars and not percents. Percents are used to describe coinsurance -- the larger percentage paid by the insurance company and the smaller percentage paid by the insured.



Copays are "per service" payments to healthcare providers (doctors, hospitals, diagnosticians, therapists, etc) -- such as $10 or $20 or $30 per visit. Deductibles are the dollar amounts insureds must pay toward their healthcare expenses before the insurance company begins to cover claims -- such as $100 to $1000 or more per person. The mechanism that divides the cost of healthcare in percentages between the insurance company and the insured is called COINSURANCE, which is NOT the same as copays.



In a coinsurance situation, where the insurance company pays 80% of covered claims and the insured pays the remaining expense, the 80% coinsurance payments by the insurance company will not be triggered until the stated deductible has been reached (or, "satisfied") per person or per family.



Coinsurance is not usually a feature of HMO plans, but is often seen in PPO plans. HMOs and PPOs both operate with copay mechanisms. HMOs may or may not have a deductible (usually not) and PPOs often include a deductible. A PPO plan that also includes coinsurance may or may not include the copays as part of the countable expenses that would satisfy the deductible (many do not) -- the contract will tell you that.



No one can "waive" the coinsurance requirement or the deductible -- especially not an agent selling a health insurance plan. Someone has to pay that expense. It can be paid by employees/insureds or by their employers, but it has to be paid to the healthcare provider one way or another.



Healthcare providers are free to voluntarily waive any or all copays or accept a reduced amount (their contract with the HMO or PPO only prevents them from charging a higher amount than the insured has contracted to pay) -- that's entirely a personal/business decision on their part. Most do not, and those who do, do not waive all copays from all patients -- they do so on a case-by-case basis, out of the goodness of their hearts.


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PostPosted: Wed Dec 26, 2012 2:27 am   Post subject: Deductible Amount  

If the deductible amount is 2000$ as per plan and the hospital bill is 1000$. Does the insurance pays the 1000$ or the patient pays the 1000$. Who has to pay the bill?


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PostPosted: Wed Dec 26, 2012 3:31 am   Post subject:   

Depends on the medical provider. Usually if they are part of the plan they will only collect the $1000 from the patient and bill the carrier for the difference.



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PostPosted: Wed Dec 26, 2012 3:34 pm   Post subject:   

Quote:
If the deductible amount is 2000$ as per plan and the hospital bill is 1000$. Does the insurance pays the 1000$ or the patient pays the 1000$


A medical insurance deductible is the amount of claims the INSURED (e.g., "patient") must pay before the insurance company begins paying claims.



Thus, if you have a $2000 deductible, until the total medical expenses reach $2000, the patient pays 100% of the cost. After the deductible has been satisfied, the amount the insurance company pays is determined according to the rest of the contract between the insurer and the insured.



Beginning on 1-1-2014, Obamacare prohibits the imposition of copays or deductibles on "preventive" health care expenses (routine checkup, wellness appointments for infants and children, screening mammograms & prostate examinations, etc). Many states and/or insurers have accelerated that scheduled and have already (or are about to implement on 1-1-2013) such requirements.


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