by frtwome » Tue Jan 20, 2009 06:31 pm
I have a 5,000. deductible on my health insurance that I have to pay first, but when I go into the doctor, do I still give them my insurance card, even though it will not be covered?
Posted: Fri Oct 09, 2009 05:45 pm Post Subject:
Always. This way the insurance company will know what amount to count towards your deductible and so long as you're in network - then you will get the renegotiated rate as well on services provided.
Posted: Wed Oct 21, 2009 08:41 pm Post Subject: High deductible health insurance
The turnarounds on high deductible health insurance plans are in reference to the great benefits.
highdeductiblehealthinsurance
Posted: Thu Oct 22, 2009 02:58 am Post Subject:
The turnarounds on high deductible health insurance plans are in reference to the great benefits.
First of all, I have absolutely no idea what this means. Flowergirl...could you clarify for me?
Next: Steven wrote:
Apart from the payment pro-rata, does it also segregate the benefit offers between 2 group plans? Otherwise, it seems to me as if the coordination of benefits prov. is all about payments.
You're pretty much right. Coordination of Benefits (COB) provisions ONLY apply in group contracts and not to individual policies which have historically pro-rated benefits between two policies based on the percentage of coverage each carrier holds compared to the total amount of coverage in force.
As an example: Let's say that you have 2 individual major medical policies with different carriers. Policy #1 has annual limits of $1,000,000, and policy #2 has annual limits of $500,000. The total amount of coverage in force is $1,500,000. Company 1 has two-thirds of the total coverage in force, and company 2 has one-third of the total coverage in force. The insured has a claim, say, for $30,000 and we'll assume that both carriers cover the loss. Carrier 1 would pay $20,000 and carrier 2 would pay $10,000, less any applicable deductibles. Co-insurance provision are commonly waived as well (not always) as each company actually would save money by protating the benefits. If company 1 was the only insurer in play, and we assume a $1,000 deductible and 80/20 co-insurance, they would have to pay $23,300 ($30k-$1k deductible = $29k x 80% = $23,200). They would have to pay more if there was a low stop-loss in place as well. So, they save money. No problem-o.
I should also state that this gets weird when comparing different types of plans, like a PPO vs. an HMO. In these areas, you have to look at the policy itself to see how it handles these situations. As well, when you consider that PPOs and HMOs aren't even insurance plans, it gets pretty complicated at times.
COB provisions deal with situation in which you have more than one group plan that applies to your loss. Consider a husband, wife and 3 kids. Everyone is covered by group plans from both parents. So, they all have "dual coverage" so to speak. COB establishes the priority of payments in the event of a loss and determines which plan is primary and which is secondary, or excess. Adoption of this rule greatly simplified how benefits were paid; prior to this it was a mess, especially with kids. The COB rules have been adopted, to the best of my knowledge, in every state as it was a mandate that came out of D.C. about 15-20 years ago. I could be wrong on the "every state" thing as the individual states have rights to make their own insurance laws. Anyway...
COB rules:
1. Coverage as an employee is primary over coverage as a dependent. So, the hubby would submit a claim to his employer's group carrier as primary and then submit any balance billing to his wife's group carrier for their consideration. Wifey would do the opposite, of course.
2. Kids are covered under the "birthday rule." Whichever parent has the earliest birthday during the year is the primary provider. My birthday is May 15th and my wife's is May 2nd. Her group plan is primary for our kids. Actual age doesn't matter- it's month and day of birth only- year of birth doesn't matter. In the event they share the same birthday (which happens a lot more than I ever thought it would), the parent who's been in their plan the longest would be primary.
3. For split households, the birthday rule goes out the window for the kids. Normally, the custodial parent becomes primary at this point unless a court order dictates otherwise.
There's a bit more, but not much. Hope this enlightened anyone who's actually interested!
InsTeacher 8)
Posted: Sat Jun 05, 2010 03:17 pm Post Subject: credit copays
did your doctors office ever call you back after filing the claim to tell you the copay didn't apply? you have a credit to use next time! is she filing the claim wrong or is the ins.co processing wrong why would my copay not apply why would they want to give it back?
Posted: Sat Jun 05, 2010 06:06 pm Post Subject:
It's possible that certain services might not be subject to a copayment. Normally, one leaves a copayment each time services are rendered.
It's doubtful that the claim is being submitted incorrectly, but don't expect the physician's office manager to be knowledgeable in all forms of insurance. If a copay was left and the insurance company says no copay is due, then the physican owes a refund or a credit toward a future service.
Posted: Wed Jun 09, 2010 11:01 am Post Subject:
i think you don't have to pay it then.
Posted: Wed Sep 14, 2011 11:30 pm Post Subject: High deductible
In July my work switched health insurance. Now we have a $2600 deductible out of pocket before the insurance will pick up anything. Well recently I had trouble with my heart and ended up in 2 ambulances, 3 hospitals, being lifeflighted to the third, and now my new heart doctor says I need surgery to correct the problem. What am I suppose to do? I can't afford to pay more than a couple dollars each week towards the deductible and the bills are piling up and my doctor wants this procedure done as soon as possible. I'm drowning and see no way to the surface.
Posted: Thu Sep 15, 2011 04:42 pm Post Subject:
Beg, borrow, or steal (well, consider the first two at least), the $2600 from family or friends, your insurance should cover much of the additional expense, and you can negotiate payments with hospitals and doctors after the fact.
Maybe your employer, who provided the insurance plan, would be willing to advance you the money.
Posted: Tue Oct 14, 2014 07:07 pm Post Subject: your deductible :anonymous1960
If the claims are processed, the deductible has already been applied, regardless if you paid it or not. Ins just process claims, they do not keep track of what you actually pay. If the claims that are processed have been applied to your deductible, then it will show in the ins system as applied. Call your ins company and ask them what you have met already. Go to a different innetwork doc/hospital for additional services, since you still owe the other providers
Posted: Tue Oct 28, 2014 01:43 am Post Subject:
Nice of you to supply an answer three years after the fact.
Add your comment