Deductibles, Co-insurance, & Out of Pocket limits

Common Health Insurance Terminology

Premium– The monthly or bimonthly fee you pay to have health insurance.

CPT codes– A medical code used for billing (a 5 digit number like 97110).

Allowed Amount– The maximum amount your particular health insurance plan will pay for a service.

Deductible– The amount you owe before your insurance begins to pay.

Co-insurance– A percentage of the allowed amount that you pay.

Out of Pocket– The maximum you will ever pay during your benefit period.

Copay– A fixed dollar amount you may pay for a service at the time you receive it. Many times, a copay does not apply towards your deductible. However, it will often apply towards your Out of Pocket Limits.

 

Deductibles, Co-insurance, & Out of Pocket limits

Once the insurance company has determined the allowed amount of the service based on their fee schedule, they consult your particular healthcare plan. Each insurance company offers different levels of plans and the coverage of those plans are all different. The amount you pay for the service provided to you is based on the plan you chose. If you have a Deductible and Co-insurance type of plan, then the allowed amount for the service is applied to your Deductible first.

Deductible Examples (with notes from the previous blog post):

A. In this example, Insurance company A received the $200 bill from the provider and determined that your allowed amount was $70 for the service. If you have a $2000 deductible, then they apply $70 to your deductible, leaving you with a remaining deductible of $1930. The insurance company will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider. The provider will adjust the $200 bill in their electronic medical records to be $70 according to the insurance’s EOB and will mail you a bill for $70.

B. In this example, Insurance company B received the $200 bill from the provider and determined that your allowed amount was $130 for the service. If you have a $2000 deductible, then they apply $130 to your deductible, leaving you with a remaining deductible of $1870. The insurance will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider. The provider will adjust the $200 bill in their electronic medical records to be $130 according to the insurance’s EOB and will mail you a bill for $130.

 

Once you have met your Deductible, the allowed amount of the service will then apply to your Co-insurance. Your Co-insurance is a split where you pay a percentage of the fee for the services and the insurance company pays a percentage of the fees. It is usually written as a fraction with the insurance’s portion first like this, 80/20, which means the insurance company pays 80% of the service costs and the member (you) pay 20% of the service costs.

Co-insurance Examples (continued from above):

A. In this example, Insurance Company A received the $200 bill from the provider and determined that your allowed amount was $70 for the service. If you have a $2000 deductible, but have accumulated enough medical expenses that you have met your $2000 deductible for the benefit period, then $70 is applied to your co-insurance amount. If you have an 80/20 co-insurance amount, meaning that the insurance will cover 80% of the service costs and you will cover 20% of the service costs, then the insurance will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider along with a check for 80% of $70, which is $56, to the provider. The provider will adjust the $200 bill in their electronic medical records to be $70 according to the insurance’s EOB, they will note the account as partially paid by the insurance by $56 and will mail you a bill for $14.

B. In this example, Insurance Company B received the $200 bill from the provider and determined that your allowed amount was $130 for the service. If you have a $2000 deductible, but have accumulated enough medical expenses that you have met your $2000 deductible for the benefit period, then $130 is applied to your co-insurance amount. If you have an 80/20 co-insurance amount, meaning that the insurance will cover 80% of the service costs and you will cover 20% of the service costs, then the insurance will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider along with a check for 80% of $130, which is $104, to the provider. The provider will adjust the $200 bill in their electronic medical records to be $130 according to the insurance’s EOB, they will note the account as partially paid by the insurance by $104 and will mail you a bill for $26.

This co-insurance split continues until you have reached your Out of Pocket limit (OOP). The OOP maximum is the maximum amount that you will pay during a benefit period. Sometimes the deductible or copays apply to the OOP maximum and sometimes they do not; they vary per plan.

Out of Pocket Examples (continued from above):

A. In this example, Insurance Company A received the $200 bill from the provider and determined that your allowed amount was $70 for the service. You have a $2000 deductible, but have had enough medical expenses that you have met your $2000 deductible for the benefit period. You also have an 80/20 co-insurance amount, meaning that the insurance will cover 80% of the service costs and you will cover 20% of the service costs. However, you have accumulated enough medical expenses to have met your $4000 Out of Pocket limit (OOP), so now the insurance will pay 100% of the service cost. The insurance will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider along with a check for 100% of $70, which is $70, to the provider. The provider will adjust the $200 bill in their electronic medical records to be $70 according to the insurance’s EOB; they will note the account as paid in full by the insurance by $70. You will not receive a bill.

B. In this example, Insurance Company B received the $200 bill from the provider and determined that your allowed amount was $130 for the service. You have a $2000 deductible, but have had enough medical expenses that you have met your $2000 deductible for the benefit period. You also have an 80/20 co-insurance amount, meaning that the insurance will cover 80% of the service costs and you will cover 20% of the service costs. However, you have accumulated enough medical expenses to have met your $4000 Out of Pocket limit (OOP), so now the insurance will pay 100% of the service cost. The insurance will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider along with a check for 100% of $130, which is $130, to the provider. The provider will adjust the $200 bill in their electronic medical records to be $130 according to the insurance’s EOB; they will note the account as paid in full by the insurance by $130. You will not receive a bill.

 

On to the next topic: When do Copays apply instead of a Deductible? Can you have both? Stay tuned for Copays and how they work.

Common Health Insurance Terminology

 

Premium– The monthly or bimonthly fee you pay to have health insurance.

CPT codes– A medical code used for billing (a 5 digit number like 97110).

Allowed Amount– The maximum amount your particular health insurance plan will pay for a service.

Deductible– The amount you owe before your insurance begins to pay.

Co-insurance– A percentage of the allowed amount that you pay.

Out of Pocket– The maximum you will ever pay during your benefit period.

Copay– A fixed dollar amount you may pay for a service at the time you receive it. Many times, a copay does not apply towards your deductible. However, it will often apply towards your Out of Pocket Limits.

 

 

Allowed Amounts: What are they and why is one bill different from another?

Each insurance company has a document called a fee schedule that lists the maximum amount that company will reimburse for a particular service. The bill that the doctor sends has one or more CPT codes on it. An insurance representative finds each of those codes on the fee schedule so they will know how much to pay for that service.

Examples:

  1. If a provider sends a code to Insurance Company A and it is $200 on the bill, but the fee schedule says that the insurance pays $70 for that service, then $70 is what is paid for that service.
  2. If a provider sends a code to Insurance Company B and it is $200 on the bill, but the fee schedule says that the insurance pays $130 for that service, then $130 is what is paid for that service.

Now we know that the allowed amounts are set by the insurance companies and that they list all of their chosen amounts in a document called a fee schedule. Each company has their own list and, while they may be similar, they are not the same.

On to the next topic: Who will be paying for the service now that the price is determined? That will depend on the particular plan that you signed up for. Stay tuned for Deductibles, Co-insurances, and Out of Pocket Limits.