Can you rephrase this in English please....?

Question

I asked about insurance covering an IUD that costs approximately $400 with an in-network provider.... this is the answer I got:

It would depend on your going to an in-network provider, then you would have to meet your deductible & you would pay 10% of the allowed amount. The balance would be written off with an in-network provider. If you went to an out of network provider you would be responsible for your deductible, 30% of the allowed amount was well as any amount that the provider chose to bill you for over the allowed amount.

So ... here's the outcome:

The procedure is $725, my maximum individual deductible is $250 which by the time I get the procedure it will be next year and my deductible will start over.... So, I'll be paying the deductible, $250 + 10% of 475 = 297.50....

Answer 1

1) You have a deductible, which is an annual cash amount that you must pay for other medical costs before we will pay any of the IUD cost. If or when you exceed that deductible we will help with the cost of the IUD.
2) You can then choose which doctor to go to, but you should check our website or catalog to find one on our list. The ones on our list are called "in-network"; that means they have signed up with us and agree to our costs.
3) If you have exceeded your deductible and go to an in-network doctor (somebody on our list), we will pay 90% of the cost and you will pay 10% -- and we will control the cost so the doctor will not gauge you.
4) If you ignore our advice and use a doctor who is not on our list, we will pay 70% of what we think the cost should be. So, if your doctor or distributor charges too much, that's your problem not ours.
5) btw, if you are healthy all year and don't have much in the way of other medical costs, you gotta pay the whole thing. Whatever that deductable is, you have to spend it before we chip in.

Answer 2

If you use a network provider...

You have coverage for the IUD. Your network deductible needs to be met before the insurer will pay out any benefits.

If the deductible has already been met, then the insurer will pay 90% and you will pay 10% (of the allowed amount).

(Given the difference in benefits, I would not recommend that you use a non-network provider. Sounds like you could be on the hook for a lot of extra $$ that way!)

Allowed amount = the amount that a network provider has agreed to accept as paid in full.

For example (let's assume that all deductibles have been met to make it easier):

$400 is the billed charge.

Network provider is contracted for $300. The insurance company pays them $270 (90%), you are billed $30 (10%). Doctors office writes off $100.

Let's use those same numbers w/$400 billed charge and assume that you went to a non-network provider...

Allowed amount is still $300. Insurance company pays $210 (70% of allowed amount). Doctors office isn't obligated to write anything off, b/c they don't have a contract w/your insurer. You get billed $190. ($90 for your 30% of allowed amount. Plus the $100 difference between the allowed amount and the billed charge...what a network doctor would have written off.)

Answer 3

I think what this person is describing is a PPO (preferred Provider Organization). A PPO in order to keep costs lower negotiate with a provider (you doctor, hospital etc) to perform certain procedures at a predetermined amount. This is why you might get a bill from the hospital called a EOB (explanation of benefits) that shows the actual charge for the procedure before the discount.

Depending on your plan, you will have a deductible that must be met each year. After that the plan might pay 80/20 (80% insurance company, 20% you)

Some procedures may only have a copay which is a flat fee you pay and the insurance company picks up the rest.

Health insurance can have many options and copays.

I hope this helps

Answer 4

First ask for a list of network providers... They have to give you that information. A 'in-network' provider means someone that they approve for you to use. Usually an 'in-network' provider is someone who agrees to the insurance companies prices that they pay for services. The deductible is what you agree to pay before the insurance company starts to pay anything. If you agree to pay a deductible of $500. Then until you rack up $500 dollars in expenses the insurance company will not pay anything. So if you go somewhere and they charge you $600. You have to pay $500 and the insurance company will pay $100. This only counts for the annual year of when you signed up for the insurance. So every year it will go back to you having to pay the first $500. Now, the 10% allowed amount is once you meet your deductible you will pay 10% for anything you have done. So you have payed the $500 deductible, now you pay 10% of whatever the cost is after that.
Out-of-Network is for people they do not have listed and have not accepted the insurances fees. Stay with an 'in-network' provider.

Answer 5

[How much we will pay will] depend on your going to an in-network provider, [ which means someone from a pre-approved list we can provide you or we should have already provided you,] then you would have to meet your deductible [which means the amount of money you have to spend out of your pocket before we start paying part or all of the bill] and you would pay 10% of the allowed amount. [ The allowed amount is an amount that we have determined is a fair and reasonable charge for a service. Anything beyond that amount that we agree to pay is not our responsibility.] The balance [beyond what we agree to pay] would be written off with an in-network provider. [In other words, if the in-network provider charges $10 for a service we only agree to allow a charge of $8, then the in-network service provider has agreed to forgive or write off that $2 balance in exchange for access to a steady stream of patients. Please note that you will have to meet your deductible and also pay 10% of the allowed amount, or $.8 in this example.] If you went to an out-of-network provider [ who is not on our list, then] you would be responsible for your deductible, 30% of the allowed amount was well as any amount that the provider chose to bill you for over the allowed amount. [In other words, the deductible still has to be satisfied before we pay anything, but in addition, instead of our paying $7.20 of the $10 charge, we would only pay 70% of $8, or $5.60. You would be responsible for all of the other $4.40, and there is no guarantee that the provider would write anything off, since we have no agreement with him.]

You might be able to find your insurer's provider list on line, in the documents they gave you when you signed up, or at the administration office if the insurance is through work or school. You should be able to call and get a copy, as well.

Answer 6

Okay, in English, it says that as long as you go to a doctor who is in your specific insurance network, once your annual deductible is met (what your deductible is and what it covers is based on your individual plan) then you pay 10% of what the insurance pays. Let's say, they're going to pay $100 of whatever's billed, let's call it $500, because providers can, in theory bill whatever they want -insurance companies are only obligated to pay what the contract says. If you've met your deductible for the year, you only have to pay $10. If you haven't met it yet, you have to pay the $100, and that's it. The doctor takes the $400 as a discount. If you chose a doctor who's not in your specific plan, then you'd have to pay $30 instead of the $10, and the doctor can choose to bill you anything up to that remaining $400.

It's a good idea to check with your specific plan - most insurance companies allow patients to check things for their plan via their website, you just need to sign up - and make sure the providers you choose are in your specific network. Some plans, like Aetna, United Healthcare, Cigna, and other nationally available plans have hundreds of networks, so the doctor can take Aetna or whatever, but they may not be in your plan - therefore, they'd be considered out of network.

Answer 7

The "allowed amount" is what the insurance company considers "reasonable and customary." An in network provider agrees to take the allowed amount for the procedure, that's part of the agreement when he decides to be an in network physician. An out of network doctor has made no agreement, so if he charges more than what the insurance company sees as reasonable and customary, then you will be responsible for the difference... In short, you have to pay 10% of the bill for an in network doctor and you'll be done, and 30% for an out of network doctor PLUS whatever he charges above reasonable and customary pricing. You have to talk to your insurance co. to find out what this customary price is.

Answer 8

It's covered, subject to your deductible & copays.

The problem is, we don't know: 1. Is the doctor in network or out of network? 2. what's your deductible? 3. What's your copay??

Assuming in network doctor, no deductible, $25 copay, you're going to pay $40 plus the $25 copay for the doctor visit.

Answer 9

call your company, they will tell you who ur in network is. if u get it from them they reduce cost for your insurance co passing the savings to you having to pay 10% if out of network there is no contract between ur company and the out of network provider