Justin Crandell Cash Pay versus Coinsurance Insurance Glossary of Terms Deductibles A deductible is the amount you must pay out of pocket for medical care before the insurance company will begin paying ID: 911206
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Slide1
Insurance 101
2018 OrthoLIFE Training
Justin Crandell
Slide2Cash Pay versus Coinsurance
Slide3Insurance Glossary of Terms
Deductibles*-
A deductible is the amount you must pay out of pocket for medical care before the insurance company will begin paying
.
Coinsurance (Not Copay)-
The
percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible
.
Out-of-Pocket Maximum
:
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.
*See Family versus Individual Deductible Next
Slide4Family Versus Individual Deductible
When a family member meets his or her individual deductible, the insurance company will begin paying according to the plan’s coverage for that member. If only one person meets an individual deductible, the rest of the family still has to pay their deductibles
.
However, out-of-pocket expenses used to meet an individual deductible are also counted toward meeting the family deductible, which is generally two to four times larger than an individual deductible
.
Once the family deductible is met, all family members will have medical expenses paid according to the plan’s coverage, even if they have not met their own individual deductibles.
Slide5Calculation Example:
Allowable costs for Treatment:
$
12,000
Deductible
: $3,000
Coinsurance: 20
%
Out-of-Pocket Maximum- $6,850.00
You'd
pay all of the first $3,000 (your deductible
).
You'll
pay 20% of the remaining $9,000, or $1,800 (your coinsurance
).
So your total out-of-pocket costs would be $4,800 — your $3,000 deductible plus your $1,800 coinsurance
.
If your total out-of-pocket costs reach $6,850, you'd pay only that amount, including your deductible and coinsurance. The insurance company would pay for all covered services for the rest of your plan year.
Slide6Eligibility Screenshots
Slide7Eligibility Screenshots
Slide8Eligibility Screenshots
Slide9Eligibility Flow Chart
Slide10Patient Responsibility Cheat Sheet