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What Is A Deductible In Health Insurance
hello and welcome to hindsight 101 where you'll learn about things that will help you in everyday life now if your medical or dental explanation of benefits or eob for short has you
What Is A Deductible In Health Insurance, confused i'm here to help you out now we're going to talk about deductibles coinsurance and co-payments so stay tuned hello i'm derek and first we're
going to get some basics out of the way like a few definitions of evo co-payment coinsurance and deductibles then we're going to talk about how an evo is different from a regular bill and then also your rights if your evo is different than your bill so if you don't want to watch all of this then skip ahead i'll put the timestamp below we're
actually going to get to an example of what a tbl looks like okay first an evo or explanation of benefits is not a bill it's basically a detailed summary of all the procedures that you have done this is not to say your evo won't reflect what your bill is but it's probably best way to describe it a pre bill so you know what to expect when your bill does
come if your bill is not the same as your evo then you need to look into that and then you have a few rights if there are issues first and foremost you can request an itemized bill from your healthcare provider and that way you can check code by code to see if everything matches up and there was no mistake also you want to check your information to
make sure that wasn't a misspelled name or social security number anything else that identifies you because mistakes always happen and that's how you can get billed incorrectly next once you get your itemized bill you also want to check for duplicate charges because your insurance company will deny those charges but the healthcare provider may
still charge them not knowing they doubled up on your charges you could always call the billing department of your health care provider and have them go through each item step by step and explain to you i've had this done because i don't know what cpt 89 code means and what that procedure actually was as opposed to when i was there and
they were giving me the procedure i don't know the technical names for them so i want to know and i'll have them sit down with me what it takes hour and a half an hour and it's your right for them to do that and lastly if all else fails there's always an appeal process now it's different for each health care provider but yes you can
appeal any charges that you have if you feel something was in the wrong oh and side note and if you don't get an explanation of benefits at all but you get a bill never pay the bill until you get that explanation of benefits you always want to make sure they match up and there's no confusion because maybe the hospital just sent you a bill before
the insurance paid for it so then you have to go through the process of getting a refund or different things like that so always wait for your evo before you pay your bill if the bill comes first so first let's talk about the definition of a deductible a deductible is what you have to pay before your insurance kicks in just like
car insurance where you may have a five-thousand-dollar deductible and then with the health care what you have to do is say your bill was a thousand but your deductible is 200 so before they'll kick in and pay any part of that thousand you have to pay at least 200 of it so and then once you pay 200 you have 800 left and the insurance company will pay the
800 800 plus 200 is a thousand know that depending on the healthcare provider every deductible is different plus whatever plan you choose so make sure you look into that before you have the procedure so you know what your payments are going to look like going into it so next let's talk about co-insurance soco insurance is a part of the bill you have
to pay after you meet your deductible maximum and basically what that means is depending on your plan the insurance provider will pay eighty percent and you have to pay 20 and there's usually a maximum for that too and once you hit that maximum then all procedures are paid for i'll show you more once we get to an example and lastly a co-payment a
co-payment is basically a payment that you have to pay to the actual doctor or hospital during the time of your visit or procedure not all plans will have a copay so make sure you look into your plan to know ahead of time if you if you need to pay once you get to the doctor's office now that we got all that out of the way let's go check on an example i'm
going to cover two examples the first one will be where the insurance company covered everything that's because i had a physical and a physical is covered under preventive care and when you have preventive care they usually cover that a hundred percent and then i'll show you another one where the insurance company didn't cover all the
expenses of the procedure so as you can see here the ax total amount billed was 324 dollars and then you have the little minus whatever is in this box will be subtracted from the 324 so there is an insurance discount and basically what that means is the insurance company and the hospital worked out an agreement that a procedure or procedures will cost
a certain amount so they'll take off a discount so whatever 324 minus two hundred and twenty one thousand twelve cents which equals 102 dollars and eighty eight cents that's how much i would have owed but since the insurance company paid for that my responsibility is zero and nothing was applied to my deductible as you can see down here
which is kind of a normal view for an eob the amount billed the insurance discounts what the insurance company paid and then what my responsibilities should be so basically when i get a bill in the mail from the hospital it should also be zero dollars so let's go to the next example now in this example similar to what we saw before the total amount
billed is 865 dollars minus whatever the discount is and whatever the insurance paid the insurance discount was 688 dollars six hundred and eighty eight dollars minus 865 dollars left a balance of 177 this procedure wasn't covered yet by insurance so they didn't pay anything so in the end i owe 177 dollars and 177 dollars was also applied to my
deductible so what that means is i owe 177 dollars so when i get a bill from the hospital it should be a hundred and seventy seven dollars and then as before you can see kind of the normal weight would look if you got this in the mail you'd see the procedure you'd see what charges were applied what the insurance discount was if your insurance company
paid anything and then what your responsibilities should be so my bill should match that this is kind of a breakdown of procedures and how much they cost so if you did have a discrepancy you would ask the hospital for an itemized bill and you want to match up the procedures and the procedure codes to make
there wasn't any double billing or something was miss coated or anything like that you also want to check your name address account number social security whatever that whatever information that identifies you you want to make sure it all matches because any of that could cause an error in your bill next we'll talk about deductibles
and coinsurance you can see an example here bob has to pay a maximum of a thousand dollars for in-network and a max of three thousand dollars for out-of-network services so basically what that means is before the insurance company pays anything bob has to at least pay a thousand dollars in network or three thousand dollars for
out-of-network services and the difference between in-network and out-of-network is your insurance company has doctors and hospitals that they've contracted with that'll charge a certain amount and that's in-network services but if you go outside of that because you have a special doctor and they charge whatever they want you can still
go to them but your deductible is higher so your out-of-pocket basically is higher bob has been to the doctor and he had some procedures done and he had to pay two hundred dollars for his in-network services he's paid 200 so subtract 200 from a thousand so he still has to pay eight hundred dollars within the calendar year before the insurance
will pay anything this is also applied to his out-of-network services so but since it's $3,000 subtracted from 200 he still has to pay two thousand and eight hundred dollars before insurance will kick in once this is covered then we're going to move over to co insurance so now we're at co-insurance and as you can see above within this calendar year bob
has met his deductible for in-network and out-of-network services so now we need to go to co insurance and basically what co-insurance is once your deductible is met co insurance kicks in and co-insurance varies by plan same as the deductible amounts vary by plan the insurance company will pay eighty percent and you have to pay twenty be it
all depends on what the procedure is and your plan so in this particular one the co insurance is fifteen hundred dollars in network and twenty five hundred dollars out of network what happens is when bob has any procedure the hospital will pay eighty percent of it and he has to pay twenty percent and he reaches a max of fifteen hundred
dollars then everything's covered a hundred percent in network or for out-of-network services again bob has to pay twenty percent the insurance company will pay eighty percent of whatever procedure he's having once he meets 25 hundred dollars every autumn network service will be covered with in that calendar year so let's look at this
example bob has $1,500 mac he's already paid in five hundred dollars remember after deductible and then the remaining he still has a thousand before everything's covered a hundred percent and then same as out of network bob has a max of 2,500 he's paid 500 they apply to both so he still has to pay 202,000 sorry out of network before all autumn
network services are covered with in that calendar year so i hope you've enjoyed this if you have any questions leave them below thank you take care
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