at UnitedHealthcare. I'm here today to define some of the most
commonly used, yet misunderstood terms in health insurance. There are four power packed words, that once
understood, will make it a lot easier for you to select
the appropriate plan for you and your family. Those words are Deductible, Co-payment, Co-insurance,
and Out-of-pocket-limit.
Even if you think you know what these terms
mean, our plans might use them differently. So, if we take a look at the word deductible
for example, if you have a home owners, or renters, or
even a car insurance policy, most of them have a deductible incorporated
into that. Health insurance plans also have deductibles but depending on what service that you have will determine if and where that deductible
will come into play in your health insurance policy. So, let's take a look at deductible.
A deductible is a member cost share. And a member cost share means that before
the insurance starts to pay you will be required to meet whatever that
deductible dollar amount is. Now the dollar amount is determined by what
plan that you pick. Not all plans have a deductible that applies.
Depending on the service that you have, whether it be a doctor visit or whether it be an outpatient surgery will determine whether the deductible applies
or whether it does not. If the deductible does apply, that means, whatever dollar amount is on that plan has
the deductible, you have to satisfy that dollar amount first,
before the insurance starts to pay. Co-payment. A co-payment is also a member cost share, but with a co-payment, it's always going to
be a fixed dollar amount.
So, an example of a co-payment might be a
doctor visit. You go into your doctor and regardless of
what they charge for that visit, your co-payment, let's say might be twenty
dollars. Prescription might be another example of a
co-payment. The medication cost might actually be thirty-seven
dollars and fifty cents but under your co-payment, that drug is only
ten dollars.
That co-payment becomes your responsibility,
the rest is paid for by the plan. Co-insurance. Co-insurance is also a form of member cost
share. But co-insurance is always going to be in
the form of a percentage.
That percentage is going to fluctuate and
differ by your service and what the cost is, or what the contracted
rate is from the provider. So, an example of a co-insurance let's say that you have an outpatient surgery outpatient surgery under all of the plans
are going to have a co-insurance component. So the way that it will work is, you have that surgery, the provider bills
UnitedHealthcare, let's say it's fifteen-hundred dollars. Because you're using an in-network provider, we have a contracted rate with that doctor.
Let's say that that surgery and the contracted
rate brings it down to a thousand. So now the thousand dollars and the fifteen-hundred you're not responsible for the difference
because the provider will write that off. So now you're left with that thousand dollars
as the contracted rate. So that thousand dollars under your plan if
it has a co-insurance of thirty percent that means that your responsible for the thirty
percent, UnitedHealthcare will be responsible for the
seventy percent.
That leaves you three-hundred dollars and that leaves UnitedHealthcare seven-hundred
dollars. That three-hundred dollars becomes your co-insurance. Out-of-pocket-limit. An out-of-pocket-limit or you may also hear
it referred to as an out-of-pocket-maximum.
Is really just what is sounds like. It is your protection, or your cap, that you cannot go out-of-pocket more than
a certain dollar amount. Now that dollar amount is going to differ
depending on which plan you pick. Choice 1,2,3 and Navigate 1,2,3 they all have different out-of-pocket limits.
So, the way that you get to that out-of-pocket
limit is a combination of three things: deductible, co-pays, and co-insurance. Now keep in mind, some of the plans don't
have deductibles, so if you pick a plan like Choice 1 or Navigate
1, the deductible isn't going to come into the
equation to go toward your out-of-pocket it would just be co-insurance and co-pays. However, the Choice 2 and 3 and the Navigate
2 and 3, they have all three components: deductibles, co-pays, and co-insurance. Every time that you have a service and you
are essentially reaching into your pocket to pay for something, in a co-pay, a co-insurance,
or in the form of a deductible those are all going into your out-of-pocket
limit or maximum.
I want you to think about that maximum, the
way that you get at that, is the deductibles, and the co-pays and the
co-insurance they're all individual buckets and they all
flow into your out-of-pocket-maximum. So co-pays will never go into deductibles, deductibles will never go into a co-insurance, and co-insurance will never go into co-payments. They're all individual but they all flow into
your out-of-pocket-limit and you will never exceed that dollar amount. Once you hit that amount and keep in mind,
it's by a calendar year, so it's January 1st to December 31st.
If you hit whatever that limit is by the plan
that you've picked, you would be at 100% coverage the rest of
the year. Also keep in mind that it resets every January
1st. Now that I've explained these terms, hopefully you will be able to look at all
the plan offerings that ASRS has for you, and you'll be able to see, by each plan, where and when you're going to be responsible
for a co-payment, a co-insurance, or a deductible. And you'll be able to really take a look at
each plan individually and compare them.
It really makes a huge difference when you
can sit down and you know where and when you're going to
be responsible putting into the equation, not just that,
but also what your premium is and you add those together and hopefully you'll
be able to select the best plan for you and for your family. I really do appreciate your time and I hope
you have a fantastic day..
No comments:
Post a Comment