What is my insurance plan telling me?

Question

I have a deductible of $500 per calendar year. My maximum out-of-pocket limit is $2,500 per calendar year. I have a copay of $15 per visit to my PCP.

So I pay the entire amount of my medical care UNTIL that amount reaches $500, then the insurance kicks in?

Answer 1

Actually, that's not entirely true.

You pay $15 per vist for your Primary Care Provider. That does not involve you deductible (and let me assure you, that's not the entire charge.) Regardless of the number of visits, you pay the same fixed price to see the PCP. However, the money you pay for copays does NOT count toward your deductible.

This is also true for prescription drugs (for most plans.)

So, for any other covered expenses (that do not have set copays), you will be required to pay the first $500 each year. Still, assuming you have a Health Maintenance Organization plan (which is a safe bet since you have a PCP), you are getting significantly discounted rates compared to what people without insurance would be paying.

After you reach the deductible, then you have a co-insurance amount that you would have to pay for any charges. The co-insurance amount is usually an 80/20 or 90/10 split (meaning that you would have to pay either 20 or 10%) up to the out-of-pocket limit for the year. Once again, though, anything that has a copayment amount (including visits to your PCP and quite likely your prescription drugs) does NOT count toward the out-of-pocket limit.

This is why, at the end of the year, you may add up your medical receipts and find that you've paid $4,000 (or more) and still never met your $2,500 out-of-pocket limit.

Answer 2

Ugh, this is hard to understand if you don't work in insurance industry. OK here goes-

Say you need surgery and it is expensive. First all your medical charges areapplied to your $500 deductible, so you are responsible for that amount assuming it is $500.00 or more. Your copay to your PCP or any other doctors does not go toward your deductible. After the $500 deductible is met, they usually pay 80% of the remainder of the bills- after the first $500,the deductible amount- until you get to where you have paid $2500. Check your policy to make sure they pay 80% and not 70%. It has to be in network or they pay less- like say 60%. So your total out of pocket limit is the $500 deductible plus the $2500 per calender year which equals $3000. Deductible and max. out of pocket are separate- I believe- I would double check. So you pay the $500 deductible and then the insurance kicks in and pays 80% of your allowable medical costs until you reach the point where you have paid $2500 at which point they pay 100% of all medical bills- if there is no limit on services such as 20 private duty nurse visits and such. I hope this helps. I know it is confusing but this is the best I can explain it. Ask your HR person or insurance agent to help you.

Read you statements from the insurance company as they pay and they should have a summary of what they paid, what you owe, what has been applied to your deductible and what you have paid out of pocket for the year. If not call them and ask for an explanation of medical benefit aka as EOMB or EOB.

Answer 3

Kinda. Is your deductible part of a cost-sharing thing? If so, you'll be paying a portion of your doctor visits until that $500 is met. Is the deductible for hospital only or procedures or labs or out of network providers? If you don't use any of those things this year, don't sweat it. (If you don't know exactly what the deductible is pertaining to- call member services for your plan and ask!) You don't have to lay out any of that $500. . The $15 copay should be paid at the visit. NEVER pay the provider towards your deductible until your insurance is billed. Anything pertaining to your deductible should be billed to your insurance - they will process it and tell the provider how much to bill you for. (It's rarely the same amount that was billed to the insurance - providers take a discount from the plan for accepting the plan.) It's also how your deductible and out of pocket is tracked. Once you hit that $2500 out of pocket - and copays often count towards it - you don't have to pay a dime more.

Answer 4

What that means is that each time you go to your PCP you will have a $15 copay. If you go anywhere else or do anything else besides an office visit with you PCP, like a surgical procedures, injections, lab work or x-rays it will be applied to your deductible. You will have to pay them until you meet $500. The maximum out of pocket means that the most you will pay out of your pocket in a year is $2500 (usually not including the deductible and copays - read the policy they are all different with that). If you meet your out of pocket your insurance will then cover your services 100%. Also after you met your deductible usually they will only cover a certain percent until your out of pocket is met. For example, they will cover 90% or 80% and you will pay the rest.

Answer 5

All insurance plans are different. I'm assuming the $500 deductible is towards hospital or other service coverage, otherwise, you'd have to pay the entire bill when you went to the Dr.'s instead of a copay. Deductibles usually don't apply to PCP visits if you have a copay. I would ask your human resource director to explain your plan but that's how it sounds.

Answer 6

Yes, medical, auto, home > deductible means you pay that amount first then the joint payment begins.
After you have paid $2500 , then the insurance company makes all the payments. The PCP may only be $15 but other items may be more like labs and outpatient procedures.

Answer 7

No , Think that you have to pay 500.00 (deductible)in medical costsout of your own pocket before your insurance kicks in. Think of it like auto insurance. You wreck your car, you pay a 500.00 deductible, then your auto insurance fixes your car. Same principle. You out of pocket max is 2500.00 per cal yr. Think of all the 15.00 office copays + your 500.00 deductible until they total 2500.00 that you would have paid out of your own pocket, that would be your out of pocket max. for the year. think if you had to pay for two office visits every month for 6 month.thats 15.00 x 2 = 30.00 per month. Now times that by 6 months (30.00 x 6 months) = 180.00 (your out of pocket max.) After your oop max has been met, then ALL your health insurance is covered at 100% for the rest of the year. you may not have to pay for anything else out of your own pocket.

CALL THE CUSTOMER SERVICE # ON YOUR ID CARD AND SPEAK TO A SERVICE REP. THAT IS THEIR JOB TO BE ABLE TO EXPLAIN THAT TO YOU....ALL INSURANCE COMPANY BENEFITS ARE DIFFERENT..

Answer 8

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