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: Tue Sep 07, 2010 05:40 am Post Subject:
No, it's the other way around. The bigger number is the insurance company's responsibility. The worst you might obtain, when it comes to coinsurance is 50/50. To go the other way doesn't make much sense, especially when you see what doctors and hospitals are actually being paid by HMOs, PPOs, and Medicare/Medicaid.
Most policies with coinsurance provisions are 70/30 or 75/25. There are a few with 60/40. Some out-of-network claims in some PPO policies might drop to the 50/50 level.
Posted: Fri Sep 10, 2010 12:47 pm Post Subject: Help Please
I really need help. I have no health insurance and I'm a insulin dependent diabetic. I also have a husband and under 1 year old daughter who have no coverage. My daughter lost Medicaid when we moved states. I've been trying to get my insurance agent (state farm) to get us insurance through them. They use Assurant Health. I've heard bad things about them. Can you put me at ease. It seems to be the most affordable, for that matter, the only insurance I can get. Also, I don't understand, are the deductibles and coinsurance per person on the policy. I'm looking at a $5000 deductible 50/50 coinsurance. Does this mean it's going to cost me $15000 before any of us can use our insurance and then still, on top of $400+ per month, going to cost another 50% of a hospital stay? What about going to just the doctor? Do you have to meet deductible and coinsurance for that? If so, I may as well keep self paying and save the insurance premium. Please help, someone.
Posted: Mon Sep 13, 2010 02:19 pm Post Subject:
Also, I don't understand, are the deductibles and coinsurance per person on the policy. I'm looking at a $5000 deductible 50/50 coinsurance. Does this mean it's going to cost me $15000 before any of us can use our insurance and then still, on top of $400+ per month, going to cost another 50% of a hospital stay?
It could mean exactly that.
Most policies with deductibles have an "individual" deductible and a "family" deductible. Some policies describe a family deductible as two or three times the deductible for one individual. So it could mean $10,000 or $15,000 in your case -- or the $5000 deductible could be the "family" deductible -- why hasn't your agent made this clear to you?
The saving grace, so to speak, will be found in the "STOP LOSS" limit in the contract. This is the most amount of out-of-pocket expense you will endure in one year, beyond premiums.
What about going to just the doctor? Do you have to meet deductible and coinsurance for that? If so, I may as well keep self paying and save the insurance premium.
Depending on the contract, physician visits may or may not be subject to the deductible or coinsurance. If they are subject to the deductible, then, yes, you will have to first satisfy the deductible before the insurance will cover some or all of the cost. So your "economic" decision/question is a legitimate concern.
It fails mostly on the possibility of a catastrophic hospitalization or illness. You could pay one monthly premium and suffer a hugely expensive medical event covered by the insurance, or you could put one month's premium in a savings account and still suffer the catastrophic event. Which will be more "profitable" (or "less costly")?
Your alternative is to find an HMO for your healthcare. If accepted, you would pay your monthly premiums, copays only when you visit network providers, and limited or no out-of-pocket expense if hospitalized. Most HMOs do not have deductibles to be concerned about. But many, if not most, HMOs may currently decline to cover you as an insulin-dependent diabetic.
Your State Farm agent may not represent any HMOs, and so has not offered that option to you. Look for another "independent" agent or make an application with an HMO directly.
Posted: Mon Sep 20, 2010 06:27 am Post Subject: health insurance
I've never been to a Dr. for this condition, but research has shown me that I have a serious bunion and I need surgery. I've only had my insurance for 3 months now and didnt have insurance prior to that. Will they consider this to be a pre-existing condition since I now need surgery?, and my deductable is $1000. will I have to pay that before surgery can be performed? Help...
Posted: Tue Sep 21, 2010 05:44 am Post Subject:
Will they consider this to be a pre-existing condition since I now need surgery?, and my deductable is $1000. will I have to pay that before surgery can be performed?
They won't consider your bunion a preexsiting condition because you need surgery, it is a preexisting condition because you've had the condition for what, maybe 10 or more years, only now it's going to be expensive to correct it. If your surgery is not excluded as a preexisting condition, then, yes, you have to satisfy the deductible in most cases before the insurance will begin paying for covered services and procedures.
Posted: Sun Oct 10, 2010 04:42 pm Post Subject:
Was reading this article and it says you pay your portion of the deductible and coinsurance to "your insurer"? Don't you pay it to the one who provided the service (i.e. hospital, lab, or doctor) once the claim has been processed?
Posted: Mon Oct 11, 2010 01:11 am Post Subject:
it says you pay your portion of the deductible and coinsurance to "your insurer"? Don't you pay it to the one who provided the service (i.e. hospital, lab, or doctor) once the claim has been processed?
Deductibles are the portion of "first dollar" expenses paid by an insured before the insurance company begins to pay any portion of a claim.
Coinsurance is the "percentage" of a claim shared between the insurer and the insured (such as "80/20" or "70/30"). When a claim is submitted, the insurer pays its contractual percentage to the provider (or as reimbursement to the insured). The insured is responsible to pay the provider the balance of the unpaid portion of the bill.
You are correct, any reference to paying deductibles and coinsurance to the insurance company is inadvertently wrong.
Posted: Fri Nov 12, 2010 06:48 pm Post Subject: coinsurance
say i have a 70/30 coinsurance. is the dr suppossed to collect what is billed or the allowed amount
Posted: Fri Nov 12, 2010 11:02 pm Post Subject:
The physician bills for his services. If you have 70/30 coinsurance, there is probably additional language in your contract that states the insurer will cover claims on the basis of "usual, customary, or reasonable". They will determine the UCR value of the physician's services and pay 70% of that (assuming you have met your deductible for the year). If your physician's charges exceed UCR, you will pay the difference between what was billed and what was paid, which will be more than 30%.
If you have a PPO with coinsurance, and your physician is in the network, then the scenario is slightly different. The physician has contracted to receive a specific amount of money for his services. If your coinsurance is 70/30, then you will pay 30% of the prenegotiated rate for "covered" services.
Posted: Sat Nov 13, 2010 05:56 pm Post Subject:
If you have a PPO with coinsurance, and your physician is in the network, then the scenario is slightly different. The physician has contracted to receive a specific amount of money for his services. If your coinsurance is 70/30, then you will pay 30% of the prenegotiated rate for "covered" services.
I think I got it...So the provider has to be within the insurance company's ppo network in order to be reimbursed at 70/30 for services they provide right?
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