Health Insurance Deductible Question

[LJSquishy]

I feel rather silly asking this, but we've never been in this scenario before so I could use your help!

What exactly happens when I meet my medical insurance deductible?

Here is what our insurance plan is like:
- $25 copay for office visit ($40 specialist)
- Covers 100% of certain things (preventative care type stuff)
- Most procedures and bloodwork is covered 80% (we pay 20%)

What I'm confused by is the fact that my insurance covers things at 80% even before I meet the deductible...so it's not like I've had to pay my entire deductible before they cover anything.

My individual deductible is $500 and I've satisfied $491 of that. So...what is the point of a deductible if they already cover things at 80%?? I don't get it!

Edited to add: My individual out of pocket maximum is $3,500.

 

[JillyBean1899]

I feel rather silly asking this, but we've never been in this scenario before so I could use your help!

What exactly happens when I meet my medical insurance deductible?

Here is what our insurance plan is like:
- $25 copay for office visit ($40 specialist)
- Covers 100% of certain things (preventative care type stuff)
- Most procedures and bloodwork is covered 80% (we pay 20%)

What I'm confused by is the fact that my insurance covers things at 80% even before I meet the deductible...so it's not like I've had to pay my entire deductible before they cover anything.

My individual deductible is $500 and I've satisfied $491 of that. So...what is the point of a deductible if they already cover things at 80%?? I don't get it!

Edited to add: My individual out of pocket maximum is $3,500.

A deductible is what you have to pay before insurance starts covering anything. So right now all the money you pay is going towards bills, insurance isn't paying for anything (except preventative care that they're required to cover).

Your out of pocket max is the maximum amount (not including premiums) that you will pay for medical services in the calendar year. So if on Jan 1 you go to the hospital and it costs $10,000, the most you'll pay is $3,500.

 

[fluffykalie]

It all depends on how they calcify claims to my understanding. Certain claims they will then pay 100% because you are over your deductible. But certain claims you will still have to pay a percentage. That's why you have the out of pocket max too. I get a 10ish page booklet every year from my work that explains where each claim falls into a certain category. You might be able to look it up online on your insures website. I have cinga and I can with them. I'm not sure about other company's websites.

 

[LJSquishy]

A deductible is what you have to pay before insurance starts covering anything. So right now all the money you pay is going towards bills, insurance isn't paying for anything (except preventative care that they're required to cover).

Your out of pocket max is the maximum amount (not including premiums) that you will pay for medical services in the calendar year. So if on Jan 1 you go to the hospital and it costs $10,000, the most you'll pay is $3,500.

Insurance is already covering 80% of my bills without me meeting my deductible. All of my bloodwork has been covered at 80%, I've even had a hysteroscopy done that was covered. That is why I'm confused. They've paid for over $3,200 of services.

 

[LJSquishy]

It all depends on how they calcify claims to my understanding. Certain claims they will then pay 100% because you are over your deductible. But certain claims you will still have to pay a percentage. That's why you have the out of pocket max too. I get a 10ish page booklet every year from my work that explains where each claim falls into a certain category. You might be able to look it up online on your insures website. I have cinga and I can with them. I'm not sure about other company's websites.

I do have Cigna, actually.

So...maybe things like bloodwork will be covered at 100% now for example? Hehe, if only I could get so lucky...I'm sure I'll have to still pay 20% for bloodwork (which I've had a ton of). So, maybe certain procedures will be covered at 100%.

My husband is going to access the insurance stuff tomorrow at work. Cigna's website doesn't go into enough detail.

 

[angwill]

With my insurance they would not pay the 80 percent on anything except for the few preventative things that are covered 100% till my deductible is met.

Normally you would pay for those labs at 100% till your deductible was met and then if they pay 80% after deductible they would start then paying the 80% and you should be billed the excess 20%. Then if you pay $3500 between the $500 deductible and your 20% deductible they should cover 100% for the rest of the year. Now maybe your plan has an exception for labs always being paid at 100% for some reason but I have never seen a plan like that. HTH

 

[wendow]

With my insurance they would not pay the 80 percent on anything except for the few preventative things that are covered 100% till my deductible is met.

This is how ours is as well. We have a 10k deductible. Other than a few preventative visits, nothing is covered at all until we reach the 10k OOP. Totally stinks and we have never had insurance like this. We always had more like what the OP is talking about. A deductible but we still had copays for regular doctor visits. But blood draws or xrays were covered at 80%. Not anymore. Now, if one of my dc is sick and I have to take them in, it's $150. My oldest dd had to get new xrays to check her scoliosis. 100% OOP

 

[bumbershoot]

I have never had insurance that covered anything (other than preventative, but I can't remember actually using one of those...we see MDs when we're sick, not when we're well) until we were done with the deductible.

Now, for a period of time it seems like they are covering it, while we are waiting for the bills to come in.

 

[angwill]

This is how ours is as well. We have a 10k deductible. Other than a few preventative visits, nothing is covered at all until we reach the 10k OOP. Totally stinks and we have never had insurance like this. We always had more like what the OP is talking about. A deductible but we still had copays for regular doctor visits. But blood draws or xrays were covered at 80%. Not anymore. Now, if one of my dc is sick and I have to take them in, it's $150. My oldest dd had to get new xrays to check her scoliosis. 100% OOP

Welcome to the new age insurance it is what they found makes them the most money and keeps people out of doctors offices and ER rooms. Our deductible is 6000 per person and 12,700 per family after that is when they start paying. To get a plan with a lower deductible the lowest I've seen is 2500 for $400 per month more.

That said, I already met my deductilbe and it's only April. The insurance company is going to hate me by year end. lol When the hospital charges $11,000 for two shots that retail cost about $1400 the deductible gets hit fast. I wonder if hopsitals are getting wise and upping their charges to make the insurance companies pay up for all the payment plans people are going to be on with the huge deductibles?

 

[JillyBean1899]

I'm on an all copay plan, so I have $0 deductible. My out of pocket max is $2,000.

OP check your coverage booklet. Some services are already covered at a partial or full rate, that's part of what the ACA laws changed. If you want to know specifics, your best bet is to call your insurance agent or company and have them explain it to you. You should also be receiving an "EOB" (explanation of benefits) every time insurance pays for something. I've been to the doctor 4 times already this year, plus had bloodwork, plus 5 RX each month, plus vaccines for school and I've received paperwork from BCBS for everything that shows what portion I paid and what portion BCBS paid for me. I'm well ahead for the year when you compare what BCBS has paid to the premiums I've paid.

 

[wendow]

Welcome to the new age insurance it is what they found makes them the most money and keeps people out of doctors offices and ER rooms. Our deductible is 6000 per person and 12,700 per family after that is when they start paying. To get a plan with a lower deductible the lowest I've seen is 2500 for $400 per month more.

That said, I already met my deductilbe and it's only April. The insurance company is going to hate me by year end. lol When the hospital charges $11,000 for two shots that retail cost about $1400 the deductible gets hit fast. I wonder if hopsitals are getting wise and upping their charges to make the insurance companies pay up for all the payment plans people are going to be on with the huge deductibles?

Ok, so ours do sound similar. Ours is 5k per person, 10k per family. We could have had a plan with a $1500 ded per person, $3k per family but it would have been $850 per month. We are pretty healthy so we opted for the higher ded plan at $420 a month. Like I said, this is a new deal for us. So I really hope we chose well. At this point, we have paid nothing towards the deductible. All we have done this year is have my dd's spine checked by her doc and do x-rays for that. It was WAY cheaper to pay OOP for everything as they gave a 35% discount for cash vs. going through insurance. We are banking on not having very much in the way of medical this year. Of course, we all know that can change completely.

I have a friend on a similar plan and she met her deductible in Jan. Her ds needs meds for seizures that run 40k a month or something crazy like that.

You may be right about the hospitals charging more so people meet deductibles faster and therefore, the hospitals get paid sooner...

 

[LJSquishy]

Wow, I guess I should consider myself lucky that insurance is paying 80% of lab work (even 100% in some cases).

Any health insurance I've ever had was like this...where things were covered 80% even before meeting the deductible. We currently have Cigna but have had Premera, Group Health, and I think one other...they've all been very similar.

 

[wendow]

Wow, I guess I should consider myself lucky that insurance is paying 80% of lab work (even 100% in some cases).

Any health insurance I've ever had was like this...where things were covered 80% even before meeting the deductible. We currently have Cigna but have had Premera, Group Health, and I think one other...they've all been very similar.

We had Cigna last year and ours was like that too (like yours is now). All our previous ones covered many services at 80 or 100% even before meeting the deductible. And we had regular copays for a sick visit. Our new insurance is a whole new deal to us. We were told it was b/c of ACA but that is clearly not the case or all insurances would be like ours. And yes, I think you should consider yourself lucky Sounds good to me!

 

[angwill]

Ok, so ours do sound similar. Ours is 5k per person, 10k per family. We could have had a plan with a $1500 ded per person, $3k per family but it would have been $850 per month. We are pretty healthy so we opted for the higher ded plan at $420 a month. Like I said, this is a new deal for us. So I really hope we chose well. At this point, we have paid nothing towards the deductible. All we have done this year is have my dd's spine checked by her doc and do x-rays for that. It was WAY cheaper to pay OOP for everything as they gave a 35% discount for cash vs. going through insurance. We are banking on not having very much in the way of medical this year. Of course, we all know that can change completely.

I have a friend on a similar plan and she met her deductible in Jan. Her ds needs meds for seizures that run 40k a month or something crazy like that.

You may be right about the hospitals charging more so people meet deductibles faster and therefore, the hospitals get paid sooner...

Wow, I think you got a great deal out $6000/$12700 plan is $582 per month. The $2500 was like $942 per month with BCBS.

Our hospitals in my area will also not even talk to someone without insurance that need things like surgery, scans, or labs done there. They simply refuse service to anyone without insurance as of Jan 1, 2014. No more lower costs for cash payers either. Last year paying cash my labs cost me $125 this year the same labs using insurance is $1065 toward my deductible. They no longer give the cash discount. It has been interesting talking to people and finding out the changes and forget about asking why their answers make no sense. lol I don't think they understand the changes.

 

[angwill]

We had Cigna last year and ours was like that too (like yours is now). All our previous ones covered many services at 80 or 100% even before meeting the deductible. And we had regular copays for a sick visit. Our new insurance is a whole new deal to us. We were told it was b/c of ACA but that is clearly not the case or all insurances would be like ours. And yes, I think you should consider yourself lucky Sounds good to me!

I don't think the insurance companies or the hospitals are sure what is new with the ACA decision on preventables. Best I could get is pap smears, mamograms, and I think colonoscopies are considered preventative that have to be covered 100% Oh and the one yearly physical per year. So far I have found none of my labs have been covered this year and I was told none will be covered due to the ACA.

I am pretty sure the only plans that will be offered with the lower deductibles and things covered before the deductible is met will be plans you get through jobs that are on a group rate. I do hope that in time they don't start doing things like the private insurance plans offer to save on costs.

 

[C-CMom]

Here is what our insurance plan is like:
- $25 copay for office visit ($40 specialist)
- Covers 100% of certain things (preventative care type stuff)
- Most procedures and bloodwork is covered 80% (we pay 20%)

.

Check your Member Handbook (or some related term, depending upon the plan). I think you likely have a plan with 2 broad types of services covered, but by a different mechanism.

For example, our Cigna plan (plans can differ even within a company depending upon what contract terms apply), we pays COPAYS for office visits, meds, and ED/Urgent care visits. Labs or simple procedures and Xrays ARE INCLUDED. Deductibles DO NOT APPLY to these services. If the service is PREVENTIVE (which has a very specific definition), the copay is NOT charged.

Hospital, rehab, maternity, "advanced" Xrays/scans, and a few other categories, however, ARE SUBJECT TO the annual DEDUCTIBLE. We pay ALL of the cost (reduced to negotiated rate if provider is "in network" only) until the deductible is met either for the individual or family level. AFTER the DEDUCTIBLE is met, then Cigna pays their 90%, we pay 10% (in your case 80/20).

Hope that helps, but I again encourage you to read YOUR handbook as plans may differ even if the "brand name" is the same.

 

[mistysue]

Wow, I think you got a great deal out $6000/$12700 plan is $582 per month. The $2500 was like $942 per month with BCBS.

Our hospitals in my area will also not even talk to someone without insurance that need things like surgery, scans, or labs done there. They simply refuse service to anyone without insurance as of Jan 1, 2014. No more lower costs for cash payers either. Last year paying cash my labs cost me $125 this year the same labs using insurance is $1065 toward my deductible. They no longer give the cash discount. It has been interesting talking to people and finding out the changes and forget about asking why their answers make no sense. lol I don't think they understand the changes.

They stopped doing cash discounts because they are panicking. Once they realize they no longer have the HUGE bills that get dumped they will calm down a bit. That random guy who comes in with a heart attack and they had to write off a $500,000 bill last year will turn into them writing off a $10,000 deductible this year. Once they figure it out they will either realize they can offer the cash discounts again, or they will get greedy. Unfortunately I think we all know which way that will go... but when they are being greedy blame the people deciding not to give the discount because it's their decision to stick with greed.

We ended up with a different plan this year that saves us a ton of money (and it's not subsidized, the cost is much lower even if we pay the max OOP along with the premiums) We've also been confused though- my kids all had their well visits with no charge to us. I went for my check up last week and was charged a co-pay. I have no idea what that was about.

 

[C-CMom]

I went for my check up last week and was charged a co-pay. I have no idea what that was about.

Two possibilities come to mind:
1. The office made a mistake, and you should get a refund. The insurance Explanation of Benefits ("EOB") that may come later or be available online may state you don't owe for the preventive care.

2. You had a check-up (preventive care), but also had some other issue addressed during the course of that visit. Depending on the codes used by the medical provider, this may have been classified as an additional service, for which the copay would be charged. Again the EOB may provide some clarity (or not?).

 

[kymom99]

Two possibilities come to mind:
1. The office made a mistake, and you should get a refund. The insurance Explanation of Benefits ("EOB") that may come later or be available online may state you don't owe for the preventive care.

2. You had a check-up (preventive care), but also had some other issue addressed during the course of that visit. Depending on the codes used by the medical provider, this may have been classified as an additional service, for which the copay would be charged. Again the EOB may provide some clarity (or not?).

I had that happen at my son's last well visit. Before that day I had taken him to a dermatologist for acne. She prescribed 2 medications, so I took them along to his pediatrician to show him what he was taking. I thought it would be a good idea for them to have the information in his records. I later got a bill for $50+ and inquired about it. The person in billing told me there was a charge for a diagnosis of acne! I told her I had already paid a specialist to diagnose that and should NOT have to pay again. She removed the charge.

 

[nyrebecca]

2. You had a check-up (preventive care), but also had some other issue addressed during the course of that visit. Depending on the codes used by the medical provider, this may have been classified as an additional service, for which the copay would be charged. Again the EOB may provide some clarity (or not?).

I work in Health Insurance and this is a HUGE thing we are seeing. Someone goes for a well visit, and during the visit brings up they had a cough, or a rash, ect, and the provider splits the visit in two (without telling the member.) We then have a claim with a well visit AND an office visit billed at the same time and all related diagnosis, and thusly a copay is assigned to the office visit portion.