On a regular basis we get questions on health insurance plans (medical insurance) and what it really covers for medical, health and wellness care. In order to better understand you health insurance coverage, lets talk about the terminology associated to a health plan and what all those words really mean. Once you understand the terms you will have a clearer picture on what your plan covers and what would be out of pocket expenses.
This is the amount you pay every month to have a health insurance plan. This monthly premium will directly affect the amount set for your annual deductible. The higher the monthly premium the lower the annual deductible and the reciprocal, a lower monthly premium translates to a higher annual deductible.
This is the set amount you pay first out of pocket each year for eligible medical expenses and services before the health insurance plan kicks in and pay for any medical expenses. Deductibles usually range from as minimal as $500.00 up to and beyond $10,000.00. You must meet this dollar amount (out of pocket) before any expenses will be paid by your health insurance plan.
One of the ways you share costs with your health insurance plan for eligible medical expenses is with a co-pay (co-payment). A co-pay is a fixed amount or percent you pay the doctor or health care provider when you receive care at the time of services. This co-pay is paid to the provider at every visit and usually ranges from $0.00 – $50.00 or if a percentage it’s usually is 20%-30%.
In addition, even after you have met 100% of your ‘out of pocket’ deductible and paid a co-pay for the visit you still have a responsibility for a percentage of the eligible medical services charges, called a coinsurance. The coinsurance rate varies per health plan and is usually a percentage. For example, if the insurance plan pays 80% of the claim for eligible medical services, you pay will have to pay 20%. There is a broad range from an 80%/20% all the way down to a 50%/50% health plan coinsurance.
Example of the Process
- Meet Nick. He loves to mountain bike and recently injured his knee on the trails. He went to his Denver Chiropractor and it was determined (by an exam) the ligaments are torn in his knee. His copay for the visit was $30, which he paid at the time of visit and service. The insurance will process remaining expenses and apply accordingly based on deductible and coninsurance.
- The next week, it was confirmed by an Orthopedic Surgeon the ligaments in the knee needed to be repaired. The knee surgery costs $5,000. His deductible is $1,000 and his coinsurance is defined as an 80%/20%.
Here’s what Nick would owe for a $5,000.00 knee surgery:
- Nick pays first the out of pocket amount of $1,000.00 per his health plan deductible
- Amount remaining for the knee surgery expenses is $4,000.00
- His Coinsurance of an 80%/20% defined on his health insurance plan
- $800.00 (20% of $4,000 – Nick pays this second)
- $3,200.00 (80% of $4,000 – Covered by his health insurance plan)
- Coinsurance Pays 80% of remaining expenses per his health insurance plan
- $3,200 (the remaining amount of the $5,000)
- Nick’s total out of pocket for knee surgery eligible medical expenses
- $1,800 ($1,000 deductible plus $800 20% coinsurance)
In Network vs. Out of Network
A healthcare professional, hospital, or pharmacy that is part of a health plan’s network of preferred providers. You will generally pay less for services received from in-network providers because they have negotiated a discount for their services in exchange for the insurance company sending more patients their way.
Out of Network
A health care professional, hospital, or pharmacy that is not part of a health plan’s network of preferred providers. You will generally pay more for services received from out-of-network providers.
There are many nuances to healthcare plans. Know what you’re signing up for and your out of pocket responsibilities. Even if your plan states Chiropractic care is considered an eligible medical expense you still need to know where you are with your deductible, co-pay, co-insurance and overall insurance coverage plan.
At M3 Chiropractic & Wellness we will verify your current insurance plan coverage to let you know a ‘snap shot in time’ on where you are with meeting your patient responsibilities and obligations. This ‘snapshot’ define what your deductible, how much you have met of deductible (paid out of pocket $250 met of $1,000), What is your coinsurance plan. 80%/20% and what is you co-pay ($30 at time of service). This information gives you valuable knowledge on what should would be any out of pocket expenses for your Chiropractic care.
If you have any questions or would like M3 Chiropractic & Wellness to check you coverage prior to your up and coming new visit, please give us a call today at 303-539-9362.
3535 W 44th Avenue
Denver, CO, 80211-1313