Deductible

What is Deductible?

Insurance deductible means patient has to pay annual fixed amount to the provider, before insurance company starts paying the benefits.

It means many plans have a maximum annual insurance deductible that patient owes. Once that annual amount met, then the insurance company starts paying the benefit to the provider for the services rendered.

For Example:

Let us assume John annual insurance deductible is $2000 and he has taken the below health care services from the provider.

Date of ServiceTotal Billed AmountInsurance Allowed AmountInsurance DeductibleInsurance paysRemarks
January,12 2018$1,000.00$800.00$800.00$0.00Remaining annual insurance deductible is $1,200.00, out of 2,000.00
January, 30 2018$1,500.00$1000.00$1000.00$0.00Remaining annual amount is $200.00, out of 2,000.00
March, 15 2018$800.00$600.00$200.00$400.00John pays copay or coinsurance if health plan requires. But no deductible amount until next year.
April,4 2018$1,600.00$1,200.00$0.00$1,200.00

In the above case, first John has to pay the $2000 amount to the provider for the services rendered to him. Once the amount $2000 met, then insurance company starts paying to the provider for the health care services performed.

Insurance Deductible is chosen from the subscriber or insured while taking the health insurance plan.

Many insurance companies offer plans like cheaper premiums with higher insurance deductible or higher premiums with lower insurance deductibles.

So it means subscriber will end up paying the lower premiums for an insurance policy when the insurance deductible is high or a higher premium when deductible is low.

In Network insurance and Out of Network insurance:

Some of the health insurance plans have both, In-network deductibles for the health care services you receive from participating provider and Out of network deductibles for the health care services you receive from non-participating provider.

Annual insurance amount for out of network services will be higher than In-network services.

Example:

Let us assume John annual In-network insurance amount is $1,000.00 and Out of network insurance amount is $2000.00 and he has taken the health care services from participating as well as non-participating providers.

In the above case insurance company starts paying the benefit for in-network services after paying the $1,000.00 towards in network bills and for out of network services the insurance company starts paying benefit after paying the $2,000.00 towards out of network bills.

It means the amount paid by John i.e. $1,000.00 towards in-network bill doesn’t count towards out of network bills. So, John has to pay $2,000.00 separately towards out of network bills if he visits out of network providers.

Note: Some health insurance plans, do count out of network amount towards in-network insurance amount. So it completely depends on the plans which subscriber opted at the time of taking health insurance.

When insurance company process or adjudicates the claim you submitted, then you can call the respective insurance company claims department and ask the following questions to representative to know the annual insurance amount met so far:

Insurance Claims Department
1May I know the Claim received date
2May I know the claim was processed
3May I know the allowed amount
4May I know what is the amount applied towards the deductible
5May I know whether It is in-network or out of network
6May I know the annual insurance amount for the patient(in-network/out of network)
7May I know how much insurance deductible amount met so far
8May I know the claim#
9May I know the call ref#

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