by renditioner » Wed Aug 27, 2008 09:12 am
A lot of you may be confused with what is coinsurance after deductibles. It is true that many individuals purchase health insurance without knowing that co-payment and deductibles are two different things. If you are purchasing health insurance you must be aware of what the policy holds for you and clearly you must be aware of the different terms used and what they mean.
What is a deductible and co-insurance?
Deductible: This is the amount that you are responsible to pay before your insurance company starts paying when a claim is made. Your premium value is also determined by the deductible that you choose. The higher the deductible, the lower will be your premium.
Co-insurance: Say you have a deductible of 2000 and the hospital bill comes around at 20, 000. As a rule you have to pay off the deductible, i.e. 2000 out-of-pocket before the health insurance company begins to pay. So you still need 18000 to pay off the rest of the bill. If you have a 80/20 co insurance and the insurance company pays 80%, you need to make 20% of the remaining 18, 000. This means that your out-of-pocket costs would be deductible + the percentage of co-insurance you have agreed upon.
Co-insurance also has a stop loss clause that lets you pay your share of the co-insurance up to a certain limit for that year after which the insurance company bears 100% of the claim amount.
The difference between coinsurance and deductible is not clear to a lot of individuals. This may create a lot of confusion when you make a claim. But if your policy has this clause you must clearly understand what will be your contribution after a claim is made. Ask your agent to explain what portion you will have to pay and what portion your insurer would pay and how both co insurance and deductible would come into play.
Co-insurance: Say you have a deductible of 2000 and the hospital bill comes around at 20, 000. As a rule you have to pay off the deductible, i.e. 2000 out-of-pocket before the health insurance company begins to pay. So you still need 18000 to pay off the rest of the bill. If you have a 80/20 co insurance and the insurance company pays 80%, you need to make 20% of the remaining 18, 000. This means that your out-of-pocket costs would be deductible + the percentage of co-insurance you have agreed upon.
Co-insurance also has a stop loss clause that lets you pay your share of the co-insurance up to a certain limit for that year after which the insurance company bears 100% of the claim amount.
The difference between coinsurance and deductible is not clear to a lot of individuals. This may create a lot of confusion when you make a claim. But if your policy has this clause you must clearly understand what will be your contribution after a claim is made. Ask your agent to explain what portion you will have to pay and what portion your insurer would pay and how both co insurance and deductible would come into play.
What does coinsurance after deductible mean?
Coinsurance after deductible means that under a health insurance policy the insured will cover a fixed percentage of the covered expenditures after the deductible has been paid. This is almost similar to co-pay except that in co-pay the insured is supposed to pay a fixed dollar amount instead of a percentage when the medical service is delivered.
Related Readings:
- Difference between co-pay and co-insurance
- What is co-insurance stop-loss?
- About co-insurance
- Co-insurance explained
I was wondering whether its coinsurance after deductible or is it the whole insurance claim..Say I have a deductible of 500$ and a 70/30 coinsurance policy .When does the coinsurance come into play?After I pay the 500$ deductible or for the whole sum of the insurance claim?
Posted: Wed May 02, 2012 12:54 pm Post Subject:
When does the coinsurance come into play?
Coinsurance is the percentage of sharing covered expenses between the insurance company and the insured. It normally applies AFTER the deductible has been satisfied. So if you have a $500 deductible and 70/30 coinsurance, you would probably have to pay the first $500 of annual medical expenses 100%, and after that, you would pay about 30% of your covered expenses.
Obamacare is changing the way "preventive" health care is paid for. By 1-1-2014, as the law currently exists, no one in America who has health insurance will have an out of pocket expense for "preventive" heatlh care (annual check up, well-baby / well-child appointments), whether there are deductibles or copays or coinsurance in the coverage. That may already be true in some policies today.
Posted: Thu May 17, 2012 05:44 pm Post Subject: Deductible
Hi Sil,
Please explain exact meaning of "NOt Subject to Deductible.
Thanks.
Posted: Tue Sep 11, 2012 04:01 pm Post Subject: copay
Lets say someone has a policy that pays 80 percent copay is 20% deductible 50$. Lets say that an office sells an in office insurance policy or discount plan for 50$ a calender year that gives a 20% discount on all procedures. does that give the office the right to waive the 20% copay from the patient insurance?
Posted: Tue Sep 11, 2012 10:16 pm Post Subject:
someone has a policy that pays 80 percent copay is 20% deductible 50$
This statement makes no sense as written, therefore your question also makes no sense.
Deductibles and copays are not the same thing. Copays are measured in dollars, not percents, and deductibles are stated as dollars and not percents. Percents are used to describe coinsurance -- the larger percentage paid by the insurance company and the smaller percentage paid by the insured.
Copays are "per service" payments to healthcare providers (doctors, hospitals, diagnosticians, therapists, etc) -- such as $10 or $20 or $30 per visit. Deductibles are the dollar amounts insureds must pay toward their healthcare expenses before the insurance company begins to cover claims -- such as $100 to $1000 or more per person. The mechanism that divides the cost of healthcare in percentages between the insurance company and the insured is called COINSURANCE, which is NOT the same as copays.
In a coinsurance situation, where the insurance company pays 80% of covered claims and the insured pays the remaining expense, the 80% coinsurance payments by the insurance company will not be triggered until the stated deductible has been reached (or, "satisfied") per person or per family.
Coinsurance is not usually a feature of HMO plans, but is often seen in PPO plans. HMOs and PPOs both operate with copay mechanisms. HMOs may or may not have a deductible (usually not) and PPOs often include a deductible. A PPO plan that also includes coinsurance may or may not include the copays as part of the countable expenses that would satisfy the deductible (many do not) -- the contract will tell you that.
No one can "waive" the coinsurance requirement or the deductible -- especially not an agent selling a health insurance plan. Someone has to pay that expense. It can be paid by employees/insureds or by their employers, but it has to be paid to the healthcare provider one way or another.
Healthcare providers are free to voluntarily waive any or all copays or accept a reduced amount (their contract with the HMO or PPO only prevents them from charging a higher amount than the insured has contracted to pay) -- that's entirely a personal/business decision on their part. Most do not, and those who do, do not waive all copays from all patients -- they do so on a case-by-case basis, out of the goodness of their hearts.
Posted: Wed Dec 26, 2012 02:27 am Post Subject: Deductible Amount
If the deductible amount is 2000$ as per plan and the hospital bill is 1000$. Does the insurance pays the 1000$ or the patient pays the 1000$. Who has to pay the bill?
Posted: Wed Dec 26, 2012 03:31 am Post Subject:
Depends on the medical provider. Usually if they are part of the plan they will only collect the $1000 from the patient and bill the carrier for the difference.
Posted: Wed Dec 26, 2012 03:34 pm Post Subject:
If the deductible amount is 2000$ as per plan and the hospital bill is 1000$. Does the insurance pays the 1000$ or the patient pays the 1000$
A medical insurance deductible is the amount of claims the INSURED (e.g., "patient") must pay before the insurance company begins paying claims.
Thus, if you have a $2000 deductible, until the total medical expenses reach $2000, the patient pays 100% of the cost. After the deductible has been satisfied, the amount the insurance company pays is determined according to the rest of the contract between the insurer and the insured.
Beginning on 1-1-2014, Obamacare prohibits the imposition of copays or deductibles on "preventive" health care expenses (routine checkup, wellness appointments for infants and children, screening mammograms & prostate examinations, etc). Many states and/or insurers have accelerated that scheduled and have already (or are about to implement on 1-1-2013) such requirements.
Posted: Mon Mar 13, 2017 05:33 pm Post Subject: Insurance Basics: Deductible & Coinsurance | Ampminsure
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