Help me understand insurance and deductables!!!!?

Question

Ok, so my insurance deductable is $1500 & I need 2 have 2 surgeries in the next couple of months w/my first 1 bein in 2 weeks. The doc is having me pay my deductable plus 20% of each surgery before he will operate.

What makes a deductable go down? I dont think that your doctor co pays go toward your deductable do they?

For example, I had some ultrasounds done before I lost my baby last month & got some bills in the mail for what the insurance didnt cover. Did what I pay to that bill go towards my deductable?

Also, they said my first shoulder surgery would be a total of $1765. (which is deductable plus 20%..which sounds to me like the 20% would be $265 after my $1500 deductable right?) Then, they said that my 2nd surgery which is the same exact surgery as the first would be $600. I dont have to pay a deductable on the 2nd surgery as far as I know, so I am wondering where they are getting $600 from?! 20% of the 1st was only $265 so why is the second $600??

Make sense to Ne1?

Answer 1

You have a $1,500 deductible 80/20 policy which means your insurance company will be responsible for 80% of anything after the first $1,500. Most insurance policies have a yearly deductible so you will only have to meet the $1,500 once this year (some deductibles are set up differently though)

Answer 2

Most insurance works the same way whether it is health, auto, or homeowners. When you buy insurance, your insurance agent is supposed to discuss the various options available to you including any state or federally required minimum coverages.

Your deductible is the amount you are expected to pay out of pocket before your insurance takes over. The larger the deductable you agree to pay, the lower your monthly insurance premium (coverage payment) will be. In your case, if you deductible is set at $1500, then any medical care recieved where the bill is $1500 or less is expected to by 100% paid by you. Anything over your insurance picks up if your policy states the service you recieve is a covered item.

For example, you shoulder surgery I would assume is a covered item and is considered necessary for your health and well being, unlike cosmetic surgery for example, which many policies will not cover. If the bill for your shoulder surgery is $1765, you are expected to pay $1500 of it (your Deductible) and your insurance will pay the remaining balance, or $265. If your second surgery is $600, it is a seperate operation and you will be required to pay the entire $600.

I don't quite understand how your doctor requires 20% beyond the deductible. If he/she agrees that they accept your insurance provider and he/she is listed in your insurace provider's network, then there shouldn't be any additional fees upfront or otherwise.

If you are able to provide the name of your insurance company and the type of plan (HMO?) you are on, it would be helpful.

Answer 3

If you already had procedures & office visits this year (most heatlth deductibles are for a calendar year), then call your insurance company and find out how much of your deductible you have satisfied this year.  Make sure it corresponds with what you have paid to your doctor so far this year (co-pays do not count toward your deductible - something that has always drove me crazy).  Anyway, they should be able to tell you this (you may even be able to get a printout).  Take that info to your doctor and show him what you have paid toward your deductible and that you only owe so much more.  So, that way your first surgery should cost you less.  It will be only 20% after you finish paying your deductible.

You should also have a maximum out of pocket limit, check this with your insurance too.  This is the maximum you pay per calendar year for your deductible ($1500) plus your 20% co-payments.