If the annual deductible is $1500 and the services provided say no coinsurance, does that mean the employee pays 100% of everything every time they go to the dr?
Total Comments: 23
Posted: Sun Aug 01, 2010 02:14 am Post Subject: Coinsurance
If the deductiable has been met, how do you figure the cost the patient pays and the cost the payer will be reimbursed.
Patient has a $250 deductiable and 80/20% coinsurance.
the usual charge is $202 and the health plan allowed charge is $176. I am so confused.
Posted: Sun Aug 01, 2010 02:42 am Post Subject:
Patient has a $250 deductiable and 80/20% coinsurance. the usual charge is $202 and the health plan allowed charge is $176. I am so confused.
Your confusion is noted. Chalk it up to insurance companies beating up on providers to accept less than their customary fee.
Assuming the $250 deductible has already been met (100% out of pocket expense for the insured), if the coinsurance is 80/20, this means the insurer will pay 80% of the "covered" expenses and the insured will pay the remaining 20%.
If the insurer establishes a limit of what it believes is "usual and customary" or "usual, customary, and reasonable", it pays 80% of that amount, and the insured pays the balance, which could be more than 20% of the total bill.
However, in an HMO or PPO plan, the insurer usually negotiates provider charges it believes is "allowable". The physician bills their usual fee (to establish that it is so that other patients can be billed the same amount). If the insurance company allows a lesser amount, the physician agrees to limit their bill to that amount, and the insurer and the patient share the allowable amount 80/20.
The insurer usually sends out an "Explanation of Benefits" that shows "Patient Savings" of the disallowed amount. It could be labeled "Insurance Company Profit".
Hope this helps clear the confusion.
Posted: Mon Nov 01, 2010 01:51 pm Post Subject: Short Term Plans
I am shopping around for affordable insurance . If a plan has a $500 deductible,the coinsurance is 80/20. This portion I understand. But this plan also includes $2,000 Coinsurance Out of Pocket Maximum after deductible. Does this mean that after I meet my deductible I will be responible for 20% of my medical expenses along with an additional $2,000 deductible ?
Posted: Wed Nov 03, 2010 01:33 am Post Subject:
Not exactly. Your out of pocket expense is 20% of your medical bills, up to $2,000 (in addition to your $500 deductible, total OOP = $2,500 per year). $2000 = 20% of $10,000. So your total medical bills for the year would have to exceed $10,500 before your insurance pays 100%.
Posted: Sat Nov 13, 2010 04:39 pm Post Subject:
Yes, no coinsurance means that there is just the deductible that has to be paid, then the insurance company will reimburse at 100% to the provider.
Posted: Sat Nov 13, 2010 07:57 pm Post Subject:
I've seen some insurance companies that have no coinsurance and just a deductible. I have also seen insurance companies with no deductible or coinsurance. So I guess it depends on the insurance company and or type of policy.
Posted: Wed Feb 02, 2011 03:55 pm Post Subject: 80%/20%
i was wondering if anyone could help me out. i work in a mental health facility and i am new here. i am checking out a future patients mental health benifits and she has no deductible but has a co-insurance of 80%/20%...how do i know how much she pays when she comes in to see the Dr ????
Posted: Wed Feb 02, 2011 08:50 pm Post Subject:
You will probably have to bill the insurance company to determine what they are willing to pay. The doctor's charges may exceed the insurance company's "usual, customary, or reasonable" charge, and they will not pay the full amount. Payments are always based on service billing codes.
Posted: Thu Oct 20, 2011 08:13 pm Post Subject: health insurance
what does it mean when it says 0%coinsurance after deductible for hospitalization and also what doesQHDHP 100%1250
Posted: Sun Oct 23, 2011 03:52 am Post Subject:
0%coinsurance after deductible for hospitalization
This means that you have no out of pocket expense for covered expenses during a hospitalization once your deductible for the year has been satisfied.
QHDHP 100%1250
I'm going to take an educated guess at this: Qualified High Deductible Health Plan (that's for sure) with $1250 deductible. The 100% might mean the plan pays 100% of expenses after the deductible has been satisfied. But it could mean something else entirely. There is something left out of the OP's description here.
Posted: Sun Aug 01, 2010 02:14 am Post Subject: Coinsurance
If the deductiable has been met, how do you figure the cost the patient pays and the cost the payer will be reimbursed.
Patient has a $250 deductiable and 80/20% coinsurance.
the usual charge is $202 and the health plan allowed charge is $176. I am so confused.
Posted: Sun Aug 01, 2010 02:42 am Post Subject:
Patient has a $250 deductiable and 80/20% coinsurance. the usual charge is $202 and the health plan allowed charge is $176. I am so confused.
Your confusion is noted. Chalk it up to insurance companies beating up on providers to accept less than their customary fee.
Assuming the $250 deductible has already been met (100% out of pocket expense for the insured), if the coinsurance is 80/20, this means the insurer will pay 80% of the "covered" expenses and the insured will pay the remaining 20%.
If the insurer establishes a limit of what it believes is "usual and customary" or "usual, customary, and reasonable", it pays 80% of that amount, and the insured pays the balance, which could be more than 20% of the total bill.
However, in an HMO or PPO plan, the insurer usually negotiates provider charges it believes is "allowable". The physician bills their usual fee (to establish that it is so that other patients can be billed the same amount). If the insurance company allows a lesser amount, the physician agrees to limit their bill to that amount, and the insurer and the patient share the allowable amount 80/20.
The insurer usually sends out an "Explanation of Benefits" that shows "Patient Savings" of the disallowed amount. It could be labeled "Insurance Company Profit".
Hope this helps clear the confusion.
Posted: Mon Nov 01, 2010 01:51 pm Post Subject: Short Term Plans
I am shopping around for affordable insurance . If a plan has a $500 deductible,the coinsurance is 80/20. This portion I understand. But this plan also includes $2,000 Coinsurance Out of Pocket Maximum after deductible. Does this mean that after I meet my deductible I will be responible for 20% of my medical expenses along with an additional $2,000 deductible ?
Posted: Wed Nov 03, 2010 01:33 am Post Subject:
Not exactly. Your out of pocket expense is 20% of your medical bills, up to $2,000 (in addition to your $500 deductible, total OOP = $2,500 per year). $2000 = 20% of $10,000. So your total medical bills for the year would have to exceed $10,500 before your insurance pays 100%.
Posted: Sat Nov 13, 2010 04:39 pm Post Subject:
Yes, no coinsurance means that there is just the deductible that has to be paid, then the insurance company will reimburse at 100% to the provider.
Posted: Sat Nov 13, 2010 07:57 pm Post Subject:
I've seen some insurance companies that have no coinsurance and just a deductible. I have also seen insurance companies with no deductible or coinsurance. So I guess it depends on the insurance company and or type of policy.
Posted: Wed Feb 02, 2011 03:55 pm Post Subject: 80%/20%
i was wondering if anyone could help me out. i work in a mental health facility and i am new here. i am checking out a future patients mental health benifits and she has no deductible but has a co-insurance of 80%/20%...how do i know how much she pays when she comes in to see the Dr ????
Posted: Wed Feb 02, 2011 08:50 pm Post Subject:
You will probably have to bill the insurance company to determine what they are willing to pay. The doctor's charges may exceed the insurance company's "usual, customary, or reasonable" charge, and they will not pay the full amount. Payments are always based on service billing codes.
Posted: Thu Oct 20, 2011 08:13 pm Post Subject: health insurance
what does it mean when it says 0%coinsurance after deductible for hospitalization and also what doesQHDHP 100%1250
Posted: Sun Oct 23, 2011 03:52 am Post Subject:
0%coinsurance after deductible for hospitalization
This means that you have no out of pocket expense for covered expenses during a hospitalization once your deductible for the year has been satisfied.
QHDHP 100%1250
I'm going to take an educated guess at this: Qualified High Deductible Health Plan (that's for sure) with $1250 deductible. The 100% might mean the plan pays 100% of expenses after the deductible has been satisfied. But it could mean something else entirely. There is something left out of the OP's description here.
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