262012Mar

Deductibles, Co-pays, Coinsurance, Out of Pocket

Vein Procedures and Insurance: What You Need to Know

It is very common for patients to ask What will I have to pay out of my pocket?  Insurance plans today can be very confusing, so let™s try to make it as simple as possible to understand.  Since it is only natural that you would want to know what your responsibility is before you decide on any treatment, the following should help you understand your financial responsibility.  It is important to note that you are responsible for knowing what your insurance covers and what it doesn™t.  At The Boca Vein Center, we make every effort to help clear up confusion about insurance coverage for our patients.  But remember, every insurance company has many different individual plans within the Network, so this is just a guide to help you work through some of the basic terms.


What is a deductible?  Simply put, this is the amount that you have to pay before your health insurance begins to pay for anything.  Deductibles only apply to those services that are considered covered by your plan (cosmetic procedures are not covered and the deductible does not apply).  So, if the deductible on your plan is $1000, then you must pay out of pocket that amount before your insurance begins to pay out for services.  Often, the amount of your deductible increases as the insurance premium decreases.  For patients who do not have a lot of serious medical conditions, they may choose a high deductible plan in exchange for a lower premium payment.


What is a co-pay/Coinsurance?  Co-pays are what you pay when you see a doctor or have a test or procedure done. This is a flat fee that can vary by insurance policy and can change for different physician specialties, facilities and procedures.  Co-pays do not count toward your deductible, as a general rule. Coinsurance is a percentage of a provider™s charge (ie: 80%/20%, 70%/30%).  This is the way you share the cost of your care with your health insurer. So if you have an 80/20 policy, then your insurance pays 80% but either you or your secondary insurance are then responsible for the remaining 20% of the cost.  Medicare is an 80/20 program and this is why most people get a secondary insurance (ie: AARP, GHI, United Healthcare, etc) to cover the 20% that Medicare does not pay.


What is Out of Pocket?  Out of Pocket is the most you will be responsible for during any one calendar year.  For example if your maximum out of pocket is $5,000.00 for a calendar year, and due to a hospital stay your charges are $10,000.00, you will only be responsible for the $5,000.00 and the insurance will pay the balance.  This applies to outpatient/office procedures as well, so if you have not met your maximum out of pocket, you may be responsible for some of the charges.


When in doubt about what you will be required to pay, always call your insurance carrier. If you can get the CPT (procedure being done) and ICD (diagnosis) codes from the physician™s office, it will be much easier to get the information that you need on your financial responsibility.   Give these codes to the person you call at your insurance company™s customer service department, and they should be able to tell you what you will be responsible for.  At The Boca Vein Center we encourage our patients to be pro-active with their insurance carriers.  While there are some things that we can do to help, most often it is up to the patient to make the call for benefits to determine what they will be responsible for.  If you have questions, we are happy to try to answer them if we can, but your best source of specific information will come from your own insurance plan service department.  (see the toll free number listed on your card).