by meganweaver11986 » Tue May 18, 2010 10:29 pm
I have a PPO plan with a $500 Deductible. I havent met my deductible yet and i need some dermatological procedures done. So in addition to my $30 Co-Pay i'm trying to find out what will my out of pocket expense be? Will i have to pay the full cost of the procedures until my deductible is met or will i pay the 70/30 split thats specified in my coverage? I think the way im understanding how the deductible is met is my insurance pays 70% of the claim and i pay 30% and that 30% will go towards my $500 deductible. And once that $500 Deductible is met then insurance will cover 100% of my claims aslong as theyre approved through their review board. Please clarify this for me!
Posted: Fri May 21, 2010 09:16 am Post Subject:
dermatological procedures
If these are strictly "cosmetic" and not medically-necessary, they may not be covered at all.
I think the way im understanding how the deductible is met is my insurance pays 70% of the claim and i pay 30% and that 30% will go towards my $500 deductible. And once that $500 Deductible is met then insurance will cover 100% of my claims as long as they're approved through their review board.
Sorry, but you do not understand this correctly.
Deductibles are normally applied to claims before any coinsurance is payable. Coinsurance is the 70/30 split you mention between the PPO and you. Copays (the $30 event) do not count toward the deductible, but some policies limit copays to an annual maximum out of pocket amount.
So here's an example: You have a $500 deductible, 70/30 coinsurance and $7500 maximum out of pocket expense (including copays). You suffer a covered medical event. Your total bill comes to $3500.
The math looks like this:
Total covered expenses = $3500
Less deductible = $ 500
Amount subject to coins = $3000
Insurer pays 70% = $2100
You pay 30% = $ 900
Copays are in addition
Only when your total out of pocket expense exceeds $7500 does the PPO cover 100% of the expenses.
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