by renditioner » Wed Aug 27, 2008 09:12 am
A lot of you may be confused with what is coinsurance after deductibles. It is true that many individuals purchase health insurance without knowing that co-payment and deductibles are two different things. If you are purchasing health insurance you must be aware of what the policy holds for you and clearly you must be aware of the different terms used and what they mean.
What is a deductible and co-insurance?
Deductible: This is the amount that you are responsible to pay before your insurance company starts paying when a claim is made. Your premium value is also determined by the deductible that you choose. The higher the deductible, the lower will be your premium.
Co-insurance: Say you have a deductible of 2000 and the hospital bill comes around at 20, 000. As a rule you have to pay off the deductible, i.e. 2000 out-of-pocket before the health insurance company begins to pay. So you still need 18000 to pay off the rest of the bill. If you have a 80/20 co insurance and the insurance company pays 80%, you need to make 20% of the remaining 18, 000. This means that your out-of-pocket costs would be deductible + the percentage of co-insurance you have agreed upon.
Co-insurance also has a stop loss clause that lets you pay your share of the co-insurance up to a certain limit for that year after which the insurance company bears 100% of the claim amount.
The difference between coinsurance and deductible is not clear to a lot of individuals. This may create a lot of confusion when you make a claim. But if your policy has this clause you must clearly understand what will be your contribution after a claim is made. Ask your agent to explain what portion you will have to pay and what portion your insurer would pay and how both co insurance and deductible would come into play.
Co-insurance: Say you have a deductible of 2000 and the hospital bill comes around at 20, 000. As a rule you have to pay off the deductible, i.e. 2000 out-of-pocket before the health insurance company begins to pay. So you still need 18000 to pay off the rest of the bill. If you have a 80/20 co insurance and the insurance company pays 80%, you need to make 20% of the remaining 18, 000. This means that your out-of-pocket costs would be deductible + the percentage of co-insurance you have agreed upon.
Co-insurance also has a stop loss clause that lets you pay your share of the co-insurance up to a certain limit for that year after which the insurance company bears 100% of the claim amount.
The difference between coinsurance and deductible is not clear to a lot of individuals. This may create a lot of confusion when you make a claim. But if your policy has this clause you must clearly understand what will be your contribution after a claim is made. Ask your agent to explain what portion you will have to pay and what portion your insurer would pay and how both co insurance and deductible would come into play.
What does coinsurance after deductible mean?
Coinsurance after deductible means that under a health insurance policy the insured will cover a fixed percentage of the covered expenditures after the deductible has been paid. This is almost similar to co-pay except that in co-pay the insured is supposed to pay a fixed dollar amount instead of a percentage when the medical service is delivered.
Related Readings:
- Difference between co-pay and co-insurance
- What is co-insurance stop-loss?
- About co-insurance
- Co-insurance explained
I was wondering whether its coinsurance after deductible or is it the whole insurance claim..Say I have a deductible of 500$ and a 70/30 coinsurance policy .When does the coinsurance come into play?After I pay the 500$ deductible or for the whole sum of the insurance claim?
Posted: Tue Jun 08, 2010 09:22 pm Post Subject: scripts
what does it mean on prescriptions when it says your cost is the greater of $15 or 40% of coinsurance?
Posted: Tue Jun 08, 2010 10:49 pm Post Subject:
what does it mean on prescriptions when it says your cost is the greater of $15 or 40% of coinsurance?
I think you are mistaken in your question. You may be confusing COPAY and COINSURANCE. Copays are normally expressed as $$ amounts ($15 or 40% of $?? is actually a dollar amount, not a percentage). Coinsurance is normally expressed as a percentage sharing arrangement -- as in 80/20 (80% insurer / 20% insured). Therefore, it makes no sense to say "40% of x%".
You prescription plan probably says "Your prescription copay is the greater of $15 or 40% of the actual cost". If that's true, any prescription valued at $37.51 or more will cost you 40% of the actual charge, which will be more than $15.00 ($15 = .40 * $37.50).
Posted: Tue Jun 22, 2010 02:59 am Post Subject: Secondary Billing/Colledtions
When processing 2nd claims and there is a deductible and coinsurance on both primary and secondary does insured have to meet both deductibles and both coinsurances in order to have the 2nd claim paid? And if there is a balance left after the secondary has paid is that supposed to be the insured's responsibilty?
Posted: Tue Jun 22, 2010 07:49 am Post Subject:
If there is primary coverage and secondary coverage, each of which has a deductible, then, yes, the deductible normally must be satisfied in each policy before coinsurance would apply. There can be language in a policy that waives the deductible under certain circumstances, so regardless of what's said here, one has to follow the contract language, and the claim must first be presented to the primary insurer.
Whenever there's a doubt as to what is or is not covered, or how the payment and coordination of benefits clauses work together, the safest bet is to contact the agent or insurer for clarification.
Posted: Thu Jun 24, 2010 12:09 am Post Subject:
I liked Carmel's question because this has been driving me insane for the first few weeks of my new job. Carmel asked "When processing 2nd claims and there is a deductible and coinsurance on both primary and secondary does insured have to meet both deductibles and both coinsurances in order to have the 2nd claim paid? And if there is a balance left after the secondary has paid is that supposed to be the insured's responsibilty?" I WILL JUST BE REFERRING TO CLAIMS (NOT SECOND CLAIMS OR WHATEVER SHE MEANT THERE).
So what I get from this is that the patient will have to owe both deductibles let's say for example the patient owed Medicare's $155.00 deductible and GHI's for example ($300.00 deductible)) before the insurance companies will split the coinsurance as 80%/20% (for example) where Medicare pays 80% of coinsurance and GHI pays 20% of coinsurance right?
Also, my other question is, if let's say Company X is a provider and Company X sends claims for dos 4/15/2010 and the patient saw Company X Provider on 4/18/2010, 4/19/2010, 4/31/2010, 5/01/2010, 05/02/2010, 05/03/2010, 05/04/2010, 05/06/2010, 05/08/2010, 05/07/2010, 05/10/2010, 05/11/2010, 05/12/2010, 05/13/2010, 05/24/2010 05/25/2010, 05/26/2010, 05/27/2010, 05/28/2010, 05/29/2010, the rest of May and up to June 6/24/2010 dos, and not all of the DEDUCTIBLE has been fully "met" (insurance terminology for applying claims to deductible) by June 24, (AND ALSO "MET" IS NOT REFERRING TO THE PATIENT PAYING IT YET), and none of the dos from 4/18/2010, 04/19/2010 and on have been sent to the insurance company yet, and then on 06/26/2010 COMPANY X PROVIDER sends the insurance company the claims, the insurance company will apply all those dos to the deductible and add up all those dos to its $155.00 Medicare deductible and try to get the deductible "met" (insurance terminology even if the patient did not PAY it yet), and then the patient will be billed the separate amounts for each dos, or will the patient be billed the full deductible amount once it has been "reached" (when claims fully "met" (as above) the deductible? **Also the secondary insurance GHI deductible would need to "met" by sending the claims to the GHI insurance so GHI can apply those claims to the deductible before there is an 80/20 split of coinsurance between Medicare and GHI on any claims submitted after the deductibles have been met? **Also, what happens to Medicare paying claims if it's deductible was "met", but GHI's deductible was not "met" yet? Also, what would the patient be responsible for in the circumstance in that question?
Finally, let's say the deductible was not PAID by the patient yet, the insurance company will not pay anything at all or do anything with a claim except bill a patient from the deductible amount that they can get from the claim right and only expect the patient to pay ONLY the deductible and insurance will cover 80/20 of all rest of bill or bills? What is an insurance company doing to a claim even if the patient has still to meet the deductible? Are they going to pay the part of the bill (if there is a coinsurance) on that claim and other ones once the patient pays his deductible fully? Will they pay their portion of the bill even if the patient takes a long time let's say, by the end of the year and finally "met" the deductible? Will they pay their portion of the bill even if the patient met his deductible for 2010 on let's say Jan 3, 2011 or will something else happen?
Thank you for any help!
Posted: Thu Jun 24, 2010 04:54 am Post Subject:
What is your "new job" and why hasn't your employer trained you?
So what I get from this is that the patient will have to owe both deductibles let's say for example the patient owed Medicare's $155.00 deductible and GHI's for example ($300.00 deductible)) before the insurance companies will split the coinsurance as 80%/20% (for example) where Medicare pays 80% of coinsurance and GHI pays 20% of coinsurance right?
Are you asking about a GHI Medicare Advantage (HMO or PPO) plan, or are you talking about some other insurance from GHI?
If you're asking about one of GHI's Medicare Advantage plans, then your whole discussion of deductibles is way off track.
When a person enrolls in a Medicare Advantage plan, they are substituting an HMO or PPO for Original Medicare Parts A & B. The Medicare beneficiary still pays their Medicare Part B premium each month, but they are no longer covered by or subject to the Part A or Part B programs. Their benefits are entirely provided by the Medicare Advantage plan instead.
There is usually no general discussion of 80/20 coinsurance for in-network care under a Medicare Advantage HMO or PPO. The GHI Medicare Choice PPOs have out-of-network copays that are higher than in-network copays, and appear to have out-of-network coinsurance of 20% or 25% depending on the service/treatment.
As far as I can tell, GHI's Medicare Choice PPO plans in New York have no deductible. Depending on the plan chosen, there is an out-of-network Out of Pocket maximum ranging from $1500 to $7500. The whole discussion of deductibles normally evaporates when discussing an HMO, Medicare or otherwise.
Also, my other question is, if let's say Company X is a provider and Company X sends claims . . .
Well, your whole scenario that follows this opening statement is not plausible. Assuming for a moment that a person was subject to Medicare Part B's $155 deductible, how could the series of 20-30 or more "dos" (whatever "dos" is referring to) not total at least $155 in 2010?
Finally, let's say the deductible was not PAID by the patient yet, the insurance company will not pay anything at all or do anything with a claim
Theoretically, that would be the case. But the whole system of Medicare billing under Part A and Part B is very different. Service providers (hospitals, physicians, others) submit Medicare claims directly to the regional Center for Medicare & Medicaid Services ("CMS"). CMS determines the medical necessity of the service, determines the allowable charge, deducts any unpaid portion of the $155 annual deductible applicable to the claim, and sends the provider payment for 80% of the balance. Any unpaid amount the patient is responsible for is billed to the patient by the service provider.
Typically, the cost of a patient's first one or two office visits in a year is sufficient to overcome the annual deductible.
insurance will cover 80/20 of all rest of bill or bills? What is an insurance company doing to a claim even if the patient has still to meet the deductible?
and
Will they pay their portion of the bill even if the patient takes a long time let's say, by the end of the year
Not entirely sure you understand the whole concept of coinsurance. The company does not pay "80/20". Coinsurance is the percentage of sharing between insurer and insured AFTER the deductible is satisfied. "80/20" means that once the deductible has been fully met, the insurance company pays 80% of the allowable charge, the patient pays the remaining 20%.
Satisfying the deductible is not "discretionary" -- the patient cannot take all year to pay the deductible (unless he has not had much in the way of medical expenses all year). When a medical insurance plan has a deductible, no claims are paid by the insurance before the deductible is satisfied (unless certain expenses are not subject to the deductible).
Will they pay their portion of the bill even if the patient met his deductible for 2010 on let's say Jan 3, 2011
This makes no sense at all. Again, the insurance company does not pay claims before the deductible is satisfied.
Digest this and see if you can post your scenarios again with better understanding.
Posted: Wed Jul 28, 2010 02:11 am Post Subject: Help
what does it mean when the insurance company states your coinsurance is subject to your deductible and copay?
Posted: Wed Jul 28, 2010 09:57 am Post Subject:
your coinsurance is subject to your deductible and copay
This is a lawyerly way to say, "Before we pay a portion of your covered expenses, you must first satisfy your deductible and any required copay amount."
Coinsurance in health insurance is the %% of sharing between the insurance company and the insured. What was once common, 80/20, is now more often 70/30, as a way to reduce premiums. But it means more out of pocket expense for insureds.
Copays are the $$ an insured pays to a service provider (doctor, hospital, lab, therapist, etc) each time a covered service is performed. Common copays are $10 to $30 for a physician visit and $50 to $100 for a trip to the Emergency Room (using an "urgent care center" instead of the ER usually means a smaller copay). Copays are separate expenses from the deductible, if any, and do not normally count toward satisfying one's deductible. Many HMOs and PPOs do not have a limit on the amount of copays that can be paid in a year. Others include them in the "stop loss".
Deductible is the $$ the insured must pay over and above any copays before the insurer will begin to apply the coinsurance formula. Each insured must satisfy their own deductible, but in a family policy, the total deductible is usually 2x or 3x the individual deductible.
The one other term I mentioned, "stop loss" (or "out-of-pocket limit") is the total expense an insured will have in one year beyond their premium payments. Some contracts include copays and deductibles in the "stop loss", some do not. An insured must read their contract (or outline of coverage) to know how the stop loss is determined. It is an insured's responsibility to keep track of expenses to make sure the insurer invokes the stop loss as required. Once the stop loss has been reached, the insurer normally pays all covered expenses for the rest of the year 100%. If the contract covers more than one person, the stop loss usually includes the expenses of all insureds, rather than a per person stop loss.
Posted: Wed Aug 18, 2010 06:51 am Post Subject:
why ur so sweet
Posted: Mon Sep 06, 2010 10:22 pm Post Subject:
is is true that in an 80/20 co-insurance, the patient pays 80% and the insurer pays 20% of the allowed charges?
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