Say my deductible is 1500 and I need a procedure that’s costs $1000 but my insurance will cover 50% before deductible. A few months before the procedure I managed to meet my deductible though does that mean they will cover 100% of it or the 50% still?

If possible try to explain like I’m five

  • ChaosCoati@midwest.socialEnglish
    8·
    2 months ago

    You need to know both your deductible and out of pocket maximum numbers. You’ve said your deductible is $1500. For the sake of this example let’s say your out of pocket max (OOP from now on) is $2500.

    For simplicity, we’ll go with your insurance’s negotiated rate for the procedure is $1000*. Meaning at the end of the day you and your insurance combined will pay the hospital $1000.

    Basically any bills up to $1500 for the year you pay 100%. Between $1500 and $2500 (or your OOP), insurance pays 50% and you pay 50%. Over $2500 insurance pays 100%.

    Some examples to illustrate:

    1. You’ve paid $400 this year so far. You pay the full $1000: $400 + $1000 = $1400 which is less than your deductible of $1500
    2. You’ve paid $1000 so far this year. You pay $750 and insurance pays $250: $500 gets you to the $1500 deductible limit so you have to pay all that, plus you pay 50% of the remaining $500 bill = $250.
    3. You’ve paid $1700 so far. You pay $500 and insurance pays $500. $1700 + $500 = $2200 which is less than your OOP of $2500
    4. You’ve paid $2300 so far. You pay $200 and insurance pays $800. 50% of $1000 = $500 but $500 would put you over your OOP of $2500. $2500 - $2300 = $200. You pay $200 and insurance pays the rest.
    5. You’ve paid $2500 so far. Insurance pays $1000
    • If your insurance’s negotiated rate for the procedure is $1000, this means that’s what the hospital and insurance have agreed to pay. A lot of times you’ll see the hospital “charge” a larger number and then have an insurance “discount” but ignore this. It doesn’t factor into deductible or out of pocket maximum calculations.
    • ALostInquirer@lemm.ee
      5·
      2 months ago

      Why is this all so convoluted and, seemingly, legal? Is this purposely convoluted to obfuscate illegal activity?

      • ChaosCoati@midwest.socialEnglish
        5·
        2 months ago

        I don’t know the actual answer. My theory is it’s this confusing so it’s hard for the general population to catch the mistakes. This allows insurance companies get out of paying as much as they’re supposed to. And hospitals don’t really care who does the paying, as long as they get paid

    • GlendatheGayWitch@lemmy.world
      2·
      2 months ago

      Don’t forget, insurance covers 50% before the deductible is met, not after. When a policy has that verbiage, usually there’s a footnote that states how those claims are handled in the future. From what I’ve seen, that could mean that insurance will cover 100% of said procedure after the deductible is met or it could mean a co-insurance of 30%.

      After the deductible is met, OP won’t necessarily pay 50%. The percentage of the bill that OP and/or insurance will pay will be on a footnote at the bottom of the blue plan overview page (at least it’s blue when looking at plans from the ACA marketplace).