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Kitten1929
LIF Adult
Member since 1/13 6040 total posts
Name:
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Need help understanding insurance coverage?
I have Cigna Open Access Plus In-Network insurance benefits. I have an 80/20 co-insurance. Individual deductibles of $2k each, family $6k. Out of pocket maximums of $5k each, family $15k.
What on earth does this mean? I have co-pays for DR visits, but how do I meet the deductibles? DS has a milk allergy and they will not cover the Nutramigen until his $2k deductible is met. At this rate, none of are going to meet out individual deductibles, and am I correct in understanding that there's ANOTHER $6k on top of that (or do our individuals constitute the family?). What does out of pocket maximums mean?
Sorry I am so clueless and I called and spoke to a rep with such a thick Southern accent I really could only determine that I need to reach DS' $2k before they will cover the Nutramigen.
I miss the good old days where insurance actually benefitted people. You could go to the DR and not worry about crazy deductibles and everything RX was covered.
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Posted 2/13/14 12:33 PM  |
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Long Island Weddings
Long Island's Largest Bridal Resource |
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Re: Need help understanding insurance coverage?
I have no clue and I feel so bad for people in this situation.
My sister is going through this and I basically understood it as a lot more is being paid out of pocket and there's nothing really you can do about it.
If you need a special formula, maybe try Craigslist?
DS needed one that was around $30 a can from what I remember and I was able to find it cheaper there.
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| Posted 2/13/14 12:39 PM |
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fins
LIF Adolescent
Member since 9/07 821 total posts
Name:
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Need help understanding insurance coverage?
If it works like mine, first you have to reach your deductible of $2,000. Once that is reached your co-insurance is 20% of the contracted rate.
For example if the dr. visit is $300 and your insurance company negotiated rate is $100 - you will pay $20 and insurance will pay $80
I am not sure why or how the co-pays work. We have deductible and co-insurance only
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| Posted 2/13/14 12:43 PM |
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Kitten1929
LIF Adult
Member since 1/13 6040 total posts
Name:
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Re: Need help understanding insurance coverage?
Posted by fins
If it works like mine, first you have to reach your deductible of $2,000. Once that is reached your co-insurance is 20% of the contracted rate.
For example if the dr. visit is $300 and your insurance company negotiated rate is $100 - you will pay $20 and insurance will pay $80
I am not sure why or how the co-pays work. We have deductible and co-insurance only
Thank you. I figured that was how the co-insurance worked, but I was thrown off by the co-pays AND deductible. I guess I will call back!
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| Posted 2/13/14 12:47 PM |
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jessnbrian
Only God knows His plan for us
Member since 4/13 7238 total posts
Name:
Jessica
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Re: Need help understanding insurance coverage?
Posted by fins
If it works like mine, first you have to reach your deductible of $2,000. Once that is reached your co-insurance is 20% of the contracted rate.
For example if the dr. visit is $300 and your insurance company negotiated rate is $100 - you will pay $20 and insurance will pay $80
I am not sure why or how the co-pays work. We have deductible and co-insurance only
Bingo, so in this example, before you meet the deductible, you would pay the entire $100 until you meet that deductible.
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| Posted 2/13/14 12:50 PM |
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Kitten1929
LIF Adult
Member since 1/13 6040 total posts
Name:
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Re: Need help understanding insurance coverage?
Posted by jessnbrian
Posted by fins
If it works like mine, first you have to reach your deductible of $2,000. Once that is reached your co-insurance is 20% of the contracted rate.
For example if the dr. visit is $300 and your insurance company negotiated rate is $100 - you will pay $20 and insurance will pay $80
I am not sure why or how the co-pays work. We have deductible and co-insurance only
Bingo, so in this example, before you meet the deductible, you would pay the entire $100 until you meet that deductible.
But how does this work when I have to pay a co-pay? So I pay $30 for the visit and then whatever the DR bills Cigna until I meet the $2k? What's the point of the co-pay?
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| Posted 2/13/14 1:08 PM |
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Blazesyth
*yawn*
Member since 5/05 8129 total posts
Name:
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Re: Need help understanding insurance coverage?
Posted by Kitten1929
Posted by jessnbrian
Posted by fins
If it works like mine, first you have to reach your deductible of $2,000. Once that is reached your co-insurance is 20% of the contracted rate.
For example if the dr. visit is $300 and your insurance company negotiated rate is $100 - you will pay $20 and insurance will pay $80
I am not sure why or how the co-pays work. We have deductible and co-insurance only
Bingo, so in this example, before you meet the deductible, you would pay the entire $100 until you meet that deductible.
But how does this work when I have to pay a co-pay? So I pay $30 for the visit and then whatever the DR bills Cigna until I meet the $2k? What's the point of the co-pay?
Once you meet your deductible, then you would pay the co-pay only. So the co-pay is sort of for after you meet your deductible.
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| Posted 2/13/14 1:17 PM |
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PrincessP
Big sister!!!!!!!!!!
Member since 12/05 17450 total posts
Name:
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Re: Need help understanding insurance coverage?
Omg, I just croaked reading this
You guys pay 2k nd 6k oop before insurance kick in.
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| Posted 2/13/14 1:20 PM |
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Kitten1929
LIF Adult
Member since 1/13 6040 total posts
Name:
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Re: Need help understanding insurance coverage?
Posted by Blazesyth
Posted by Kitten1929
Posted by jessnbrian
Posted by fins
If it works like mine, first you have to reach your deductible of $2,000. Once that is reached your co-insurance is 20% of the contracted rate.
For example if the dr. visit is $300 and your insurance company negotiated rate is $100 - you will pay $20 and insurance will pay $80
I am not sure why or how the co-pays work. We have deductible and co-insurance only
Bingo, so in this example, before you meet the deductible, you would pay the entire $100 until you meet that deductible.
But how does this work when I have to pay a co-pay? So I pay $30 for the visit and then whatever the DR bills Cigna until I meet the $2k? What's the point of the co-pay?
Once you meet your deductible, then you would pay the co-pay only. So the co-pay is sort of for after you meet your deductible.
Wow, things were explained very differently in our meeting. I realize I was not knowledgeable, but this hardly sounds like a good plan.
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| Posted 2/13/14 1:21 PM |
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Kitten1929
LIF Adult
Member since 1/13 6040 total posts
Name:
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Re: Need help understanding insurance coverage?
Posted by PrincessP
Omg, I just croaked reading this
You guys pay 2k nd 6k oop before insurance kick in.
Gee thank you.
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| Posted 2/13/14 1:21 PM |
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BargainMama
LIF Adult
Member since 5/09 15657 total posts
Name:
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Re: Need help understanding insurance coverage?
Posted by Kitten1929
Posted by Blazesyth
Posted by Kitten1929
Posted by jessnbrian
Posted by fins
If it works like mine, first you have to reach your deductible of $2,000. Once that is reached your co-insurance is 20% of the contracted rate.
For example if the dr. visit is $300 and your insurance company negotiated rate is $100 - you will pay $20 and insurance will pay $80
I am not sure why or how the co-pays work. We have deductible and co-insurance only
Bingo, so in this example, before you meet the deductible, you would pay the entire $100 until you meet that deductible.
But how does this work when I have to pay a co-pay? So I pay $30 for the visit and then whatever the DR bills Cigna until I meet the $2k? What's the point of the co-pay?
Once you meet your deductible, then you would pay the co-pay only. So the co-pay is sort of for after you meet your deductible.
Wow, things were explained very differently in our meeting. I realize I was not knowledgeable, but this hardly sounds like a good plan.
Well visits you shouldn't be paying a copay for though. Just sick visits, specialists, etc. Including women's care (annual pap..no co pay).
Message edited 2/13/2014 1:26:15 PM.
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| Posted 2/13/14 1:25 PM |
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Goobster
:)
Member since 5/07 27557 total posts
Name:
:)
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Re: Need help understanding insurance coverage?
Are you asking about an in network deductible or an out of network deductible? I understand the out of network but I never understand the in network one. If you are in network, wouldn't that mean it's covered under the plan?
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| Posted 2/13/14 1:27 PM |
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Kitten1929
LIF Adult
Member since 1/13 6040 total posts
Name:
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Re: Need help understanding insurance coverage?
Posted by Goobster
Are you asking about an in network deductible or an out of network deductible? I understand the out of network but I never understand the in network one. If you are in network, wouldn't that mean it's covered under the plan?
Yes, in-network. I guess I just didn't understand things properly in the benefits meeting. I totally understood the co-insurance, but I was confused about how the in-network deductible worked in conjunction with the co-pay.
So I pay $1900 annually for this permium, then I need to pay another $8000 before anything is covered, and even then it's at 80%. And where does the out of pocket maximum come into play?
I really have no words.
Message edited 2/13/2014 1:32:34 PM.
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| Posted 2/13/14 1:31 PM |
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blue11
LIF Adult
Member since 2/11 1706 total posts
Name:
kat
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Need help understanding insurance coverage?
Co pay, co insurance and deductibles are all different things. Co pay is usually a flat set amount for doctor visits, er visit. I have a 20 co pay for any sick visit to my physician and 100 co pay for an er visit. A deductible is usually incurred for a hospitalization, an outpatient procedure or medical equipment or something like that. Same as your car insurance, if your damage is less than deductible you pay it all, if its more you pay the deductible then insurance kicks in. co insurance is after you meet the deductible, you are then responsible for x% but you still have an out of pocket maximum so you only pay until you hit that
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| Posted 2/13/14 1:34 PM |
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beanie571
:-P
Member since 5/07 2509 total posts
Name:
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Need help understanding insurance coverage?
Ok just read your post that these are in network deductibles and coinsurance. How sucky! Sorry!
Message edited 2/13/2014 1:38:27 PM.
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| Posted 2/13/14 1:36 PM |
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BargainMama
LIF Adult
Member since 5/09 15657 total posts
Name:
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Re: Need help understanding insurance coverage?
Posted by Kitten1929
Posted by Goobster
Are you asking about an in network deductible or an out of network deductible? I understand the out of network but I never understand the in network one. If you are in network, wouldn't that mean it's covered under the plan?
Yes, in-network. I guess I just didn't understand things properly in the benefits meeting. I totally understood the co-insurance, but I was confused about how the in-network deductible worked in conjunction with the co-pay.
So I pay $1900 annually for this permium, then I need to pay another $8000 before anything is covered, and even then it's at 80%. And where does the out of pocket maximum come into play?
I really have no words.
$1900 a year is not that expensive though. So that is probably why the deductible is so high.
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| Posted 2/13/14 1:44 PM |
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Re: Need help understanding insurance coverage?
Posted by BargainMama
Posted by Kitten1929
Posted by Goobster
Are you asking about an in network deductible or an out of network deductible? I understand the out of network but I never understand the in network one. If you are in network, wouldn't that mean it's covered under the plan?
Yes, in-network. I guess I just didn't understand things properly in the benefits meeting. I totally understood the co-insurance, but I was confused about how the in-network deductible worked in conjunction with the co-pay.
So I pay $1900 annually for this permium, then I need to pay another $8000 before anything is covered, and even then it's at 80%. And where does the out of pocket maximum come into play?
I really have no words.
$1900 a year is not that expensive though. So that is probably why the deductible is so high.
I'm guessing the same thing.
At my last job, I was paying $357 a WEEK for my family's health insurance.
And I don't make a super high salary.
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| Posted 2/13/14 1:47 PM |
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blue11
LIF Adult
Member since 2/11 1706 total posts
Name:
kat
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Re: Need help understanding insurance coverage?
Posted by Kitten1929
Posted by Goobster
Are you asking about an in network deductible or an out of network deductible? I understand the out of network but I never understand the in network one. If you are in network, wouldn't that mean it's covered under the plan?
Yes, in-network. I guess I just didn't understand things properly in the benefits meeting. I totally understood the co-insurance, but I was confused about how the in-network deductible worked in conjunction with the co-pay.
So I pay $1900 annually for this permium, then I need to pay another $8000 before anything is covered, and even then it's at 80%. And where does the out of pocket maximum come into play?
I really have no words.
Usually your copay does not count towards the deductible. Sounds like you have a high deductible plan. You would stop paying co insurance when you meet your out of pocket max.
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| Posted 2/13/14 1:52 PM |
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Kitten1929
LIF Adult
Member since 1/13 6040 total posts
Name:
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Re: Need help understanding insurance coverage?
Posted by BargainMama
Posted by Kitten1929
Posted by Goobster
Are you asking about an in network deductible or an out of network deductible? I understand the out of network but I never understand the in network one. If you are in network, wouldn't that mean it's covered under the plan?
Yes, in-network. I guess I just didn't understand things properly in the benefits meeting. I totally understood the co-insurance, but I was confused about how the in-network deductible worked in conjunction with the co-pay.
So I pay $1900 annually for this permium, then I need to pay another $8000 before anything is covered, and even then it's at 80%. And where does the out of pocket maximum come into play?
I really have no words.
$1900 a year is not that expensive though. So that is probably why the deductible is so high.
I didn't say it was high. I was just laying out what I am paying. I realize that is very low, but if I had to pay more to get a lower deductible I would have.
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| Posted 2/13/14 1:54 PM |
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Kitten1929
LIF Adult
Member since 1/13 6040 total posts
Name:
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Re: Need help understanding insurance coverage?
Posted by MorningCuppaCoffee
Posted by BargainMama
Posted by Kitten1929
Posted by Goobster
Are you asking about an in network deductible or an out of network deductible? I understand the out of network but I never understand the in network one. If you are in network, wouldn't that mean it's covered under the plan?
Yes, in-network. I guess I just didn't understand things properly in the benefits meeting. I totally understood the co-insurance, but I was confused about how the in-network deductible worked in conjunction with the co-pay.
So I pay $1900 annually for this permium, then I need to pay another $8000 before anything is covered, and even then it's at 80%. And where does the out of pocket maximum come into play?
I really have no words.
$1900 a year is not that expensive though. So that is probably why the deductible is so high.
I'm guessing the same thing.
At my last job, I was paying $357 a WEEK for my family's health insurance.
And I don't make a super high salary.
If I had to pay $357/week for insurance, how you can afford to live?
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| Posted 2/13/14 1:55 PM |
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Re: Need help understanding insurance coverage?
It sucks.
I used to get really resentful because I worked in health care and knew how much they were making off 1 case alone because I used to write the treatment plans.
A lot of my old co-workers have opted out and are paying OOP because it's so much cheaper, even with the deductibles, especially if you are generally healthy and don't need to use it a lot.
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| Posted 2/13/14 1:56 PM |
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PitterPatter11
Baby Boy is Here!
Member since 5/11 7619 total posts
Name:
Momma <3
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Need help understanding insurance coverage?
Usually deductible plans do not have co-pays. I would assume the co-pay will be applied as partial payment once you get a bill.
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| Posted 2/13/14 1:58 PM |
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BargainMama
LIF Adult
Member since 5/09 15657 total posts
Name:
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Re: Need help understanding insurance coverage?
Posted by Kitten1929
Posted by BargainMama
Posted by Kitten1929
Posted by Goobster
Are you asking about an in network deductible or an out of network deductible? I understand the out of network but I never understand the in network one. If you are in network, wouldn't that mean it's covered under the plan?
Yes, in-network. I guess I just didn't understand things properly in the benefits meeting. I totally understood the co-insurance, but I was confused about how the in-network deductible worked in conjunction with the co-pay.
So I pay $1900 annually for this permium, then I need to pay another $8000 before anything is covered, and even then it's at 80%. And where does the out of pocket maximum come into play?
I really have no words.
$1900 a year is not that expensive though. So that is probably why the deductible is so high.
I didn't say it was high. I was just laying out what I am paying. I realize that is very low, but if I had to pay more to get a lower deductible I would have.
I didn't say you said it was high. I was pointing out why your deductible is likely so high.
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| Posted 2/13/14 2:08 PM |
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BargainMama
LIF Adult
Member since 5/09 15657 total posts
Name:
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Re: Need help understanding insurance coverage?
Posted by PitterPatter11
Usually deductible plans do not have co-pays. I would assume the co-pay will be applied as partial payment once you get a bill.
All of the Healthcare Exchange plans have deductibles and co-pays, so I'm sure it's becoming more commonplace amongst other carriers as well.
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| Posted 2/13/14 2:09 PM |
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PitterPatter11
Baby Boy is Here!
Member since 5/11 7619 total posts
Name:
Momma <3
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Re: Need help understanding insurance coverage?
Posted by BargainMama
Posted by PitterPatter11
Usually deductible plans do not have co-pays. I would assume the co-pay will be applied as partial payment once you get a bill.
All of the Healthcare Exchange plans have deductibles and co-pays, so I'm sure it's becoming more commonplace amongst other carriers as well.
Maybe they are moving towards this so they can guarantee some sort of payment - I am sure there are people who do not pay their bills and this at least insures the doctor gets something.
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| Posted 2/13/14 2:12 PM |
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