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OKAY! Since I explain this to patients every. single. day. "My ins didn't pay for it?" Insurances, typically, do not pay for everything. It depends on YOUR contract, the product you bought and are paying for. Ins are not about the patient, they are For-Profit Companies.
All ins are not the same and they will throw out words that sound good like "Major medical/No copays/Co-ins" that don't actually tell you reality. You need to ask SPECIFICS on how this will work for you. "Do I need a referral? Do I have a copay? No? Then do I have a deductible?"
"No copays" sounds REALLY good to some people... until they realize that means "I don't have a copay, I have a deductible." Basically, they didn't lie, they avoided certain truths in order to manipulate you. (Thank you, Zach).
A Deductible is the amount of money your insurance makes you pay out of your own pocket before they start paying. Medicare has a $185 ded this year. Average ins policy has a ded of SEVERAL THOUSAND before ins starts paying.
It's like an insurance companies insurance policy on you. "If you agree to pay your monthly premiums and meet your ded before we ever start paying, then it's unlikely you'll get an expensive surgery and then cancel your insurance." Which was a problem.
When buying a policy, keep in mind that the lower your monthly premium (like your car note, payments broken up to buy a single expensive product), the LOWER your mnthly pymt, the HIGHER your deductible will be. If you pay less up front, you'll pay more toward medical bills.
The insurance is going to get its money, it's just a matter of if you do it on the monthly or if you do when you break your arm and have to fork out $500.00 you weren't prepared to spend.
"What is my copay?" -- Copay only covers office vists if you also have a ded. Meaning, the ov is covered under the copay, but those xrays you got will be billed to the ded and you will get a bill.
"What's my ded?" -- amt of $$ you pay before ins starts paying majority
"What's my ded?" -- amt of $$ you pay before ins starts paying majority
"What is my co-insurance?" --Co-ins is when the ins picks up AFTER you satisfy the ded. If your ded is $1,000, you pay that toward medical bills BEFORE insurance starts paying. Then the insurance gets billed, they pay their percent, you get the other.
"What is my Out of Pocket Cost/Stop Loss Cost?" -- Maximum amount of money you spend out of your pocket toward your medical bills. This may or may not apply to copays. So even if your OOP is met, you may still have to pay copays, but everything else is covered.
Durable Medical Equipment (DME) -- boots, braces, slings, wheelchairs, sandals, walkers, potties, beds, etc. are always going to be billed to the ded if you have one, even if your insurance covers your office visits. Ask if your ins COVERS DME and at what rate.
Certain insurances do not cover DME. Or if you have a high ded that isn't met, see if you can't get what you need from Walmart and order it online. You'd be amazed what they offer.
You would research a car or house/area before buying, would want to know all about it. You need to do the same with your insurance. It is not an umbrella. It's generally best to go with most expensive plan you can afford. Life WILL happen. "I don't get sick." LIFE HAPPENS.
On the subject of having a secondary insurance, do not think that just because you have two ins means you aren't going to have to pay anything.
Ask if your secondary covers the ded of the primary insurance.
Ask if the secondary has a ded.
HOW do they work together?
Ask if your secondary covers the ded of the primary insurance.
Ask if the secondary has a ded.
HOW do they work together?
And know that if the primary ever denies something, that does not mean the secondary will pay it. Generally, if the primary denies something as non-covered, then the secondary will not pay on principle, even if it's smthg they normally cover.
It sounds confusing and overwhelming and everyone's brain goes TLDR, but it's actually NOT, it's just UNFAMILIAR.
Referrals> Copays> Deductibles> Co-insurance> Out of pocket/Stop loss.
These are the main things you need to always ask about. They work in that order.
Referrals> Copays> Deductibles> Co-insurance> Out of pocket/Stop loss.
These are the main things you need to always ask about. They work in that order.
Also, in-network or out-of-network. if you are going to a new doctor or specialist, always call before your appointment to ask if they are in-network or out-of-network with your ins. This controls how much you pay or if your ins pays at all.
It is the responsibility of THE PATIENT to find these things out, not the doctor's office. The patient has to take the initiative. This is a product YOU bought. You should know (and are expected to understand) how it works because it's a product you got off the shelf and bought.
