Health insurance questions: I have 2 questions????

Question

Isnt a co-pay just that, a co-pay? I mean isnt that all your responsible for? Like if I go to the doctors I pay a co-pay of $25 and they dont bill me any difference. We have a $100 co-pay for emergency room visits but they always bill us the difference (like if deductible not met and 20%) I thought co-pay was it, just like at the doctors office. Next question is this. We have a Max individual $500 deductible with a $1500 Max family deductible. How can I be out (mine) an amount of $640 and total family met of $1643??? Does it sound like they are not processing claims right?? any info on these 2 questions would be appreciated.

Answer 1

Check your coverage - if you have just a copay for doctor/hospital inpatient/hospital outpatient or if there's a deductible for ANY portion of that (labs, procedures, in or out of network, etc.) it will be spelled out.

Some plans have just a copay for in network doctor's visits, and that's it. Some plans have a copay and then a deductible for hospitals - whether or not you're admitted, or just in the ER, or just have testing done there. (Usually, if the copay for the hospital is $100 or less, there's a deductible somewhere.) Make sure the hospital is in-network - sometimes there's additional charges for out of network or non preferred. (like the additional deductible)

As far as the deductible being met - keep ALL your explanation of benefits (EOBs) - if you've paid more than or are being charged more than your deductible, it's possible two claims crossed and it was an error on the part of the insurance. Call them as soon as you get a bill or an EOB and tell them you feel it's an error and ask that they reprocess the claim. Because you're the one paying them, your opinion means more to them than the doctor's office who is trying to squeeze money out of them. (Make sure you notify the doctor's office that you've asked for reprocessing so they don't keep billing you until the claim's been reprocessed - usually four to six weeks.)

Answer 2

No, with health insurance, there is usually a co-payment, AND a deductible.

What usually happens, after you meet the deductible (ie, you've paid out $500 per person, or $1500 max), if you have a major medical expense, the insurance company THEN pays 80% of that, and you ALSO have to pay an additional 20%, until you reach a "maximum" per year, usually $5,000 or some such.

So, you pay 100% of the first $500 of expenses per person, then 20% of the next several thousand, with each office visit requiring a $25 co-pay.

You can call the number on the back of your insurance card, and ask them to review the whole thing for you.

Answer 3

you really have to refer to your certicicate of coverage to see what your plan is. now a days it is more likely that some services have a copay and others have a deductible b/c the cost of health care is so high that employers share the cost with their employees by giving them more out of pocket.
with a standard deductible, the way it works for a family is 1 person meets the individual deductible then their claims pay at a coinsurance level and then collectively the rest of the family has to work to meet the family deductible (meaning the rest of the ded). once that is met then claims pay at a coinsurance (percentage). you have a max on the coinsurance, so if you meet the max of coins and add that to the deductible you eqaual your out of pocket maximum. if your plan has copays for certain services, those copays will not work to meet the deductible or out of pocket max. it sounds like your plan is a mix between ded/coins and copays. depending on the service depends on the expense.
also, if you see and in network provider, you should never be balanced billed. that means the difference between the providers charge and the allowance from the insurance carrier. example - $200 charge - allowed amount is $120 - you pay your $20 copay the insurance covers the other $100 and then the $80 difference is written off. no one pays that.
hope this helps....

Answer 4

It sounds like you may be having things done that do not apply to a copay. Certian things, like x-rays or minor in office surgery, drugs administered in the drs office, may not fall under the copay and are subject to the deductible and then paid at your coinsurance rate (80-90% usu). Even things you may not consider surgery are considered procedures because of the way it is coded. Anything that starts with a 1 through a 6 is usually considered surgery. This could be a lesion removal, having fluid aspirated from a joint, etc. You should have a listing in your policy booklet of what is not considered under a copay.

You also have what is called out of pocket. You may have a $500 deductible, but also a $2000 out of pocket. Sometimes the deductible is considered part of the out of pocket, but it may not be. Claims will not pay at 100% (non copay things) until that out of pocket is reached.

Answer 5

The answers to both questions depend on the terms of your contract, your carriers' business practices and the state you live in. This is where finding a good agent to work with can be a huge advantage. A local agent will be able to walk you through these issues and any others which come up. And if there's a gray area, a good agent can be your advocate. And in most states and with most carriers, you don't pay more for buying through an agent. And since they're paid every month you keep the coverage, you have every right to demand their help.

The key, of course, is how to find a good agent. The yellow ages aren't always that helpful. If you're in California, you can find quality agents who commit to providing strong service and have met other requirements at www.InsuranceNeighborhood.com (it's sort of like a 1-800-DENTISTS for insurance agents).

Outside of California your best bet is to go the www.NAHU.org. This is the largest trade association for agents specializing in health insurance. In the "Consumer Information" tab click on the "Find an Agent" link.

Answer 6

"a nobody from Oklahoma" knows her stuff. I wish she worked for me! I own an agency in Oklahoma. Call your agent - they know the particulars of your specific plan you currently have. By the way - FYI - your deductible will start over again today as they are calendar year deductibles.

Answer 7

I don't see what your question is.