What's the difference between deductible and total out of pocket expense when referring to health plans?

Question

I have no experience with health plans. Please help me understand!

Answer 1

Your deductible is the amount you have to pay before your insurance begins paying their share.

Co-insurance is the percentage that you and your insurance pay until your out of pocket amount is met.

Example: $500 ded then 80% to $5000 stop loss 100% thereafter.

You pay the first $500 in eligible charges and 20% of the next $5000 (you have a $1,000 out of pocket)

Answer 2

You have to pay a deductable for your insurance, usually that is out of pocket pay. Once you pay that your insured. The out of pocket means that if the situation is more than you agreed to be covered for, you are expected to pay the remainder.

Answer 3

Deductible is the amount you owe for covered service. The deductible must be satisfied before any payment is made on claims.  

Out of pocket applies after you satisfy the deductible. There is probably some sort of coinsurance. This means that you pay a certain percentage and your insurer pays a certain percentage until you meed a total out of pocket maximum.

Here is an example:

$500 deductible

20% ccoinsurance

$2000 out of pocket maximum

Before any claims are paid at all you must meet the $500 deductible. After you meet that you will pay 20% and the insurer will pay 80%. When your 20% totals $2000 then the claims will start processing at 100%.  Until the end of the contract year, then it starts all over.

Your claims will process by date of service, not the date they were submitted. If you are using participating providers, the deductible and coinsurance for covered services will apply to the UCR or contrallually agreed rate that the insurer has with the medical provider.  You pay the contrated amount, any difference in acutal charge and UCR is written of by the care provider, due to their contratual obligations with your insurance company.

Answer 4

The deductible is the minimum you pay, the total out of pocket is te maximum you pay.

The insurance doesn't START paying, until AFTER you've paid bills equal to the deductible.  Then, you KEEP paying copays and coinsurance, until you reach the total out of pocket maximum.

Answer 5

The deductible is the amount you have to pay before coverage begins. For example, usually you have to pay the first $200 (or $500 depending on your insurance plan)

Total out of pocket expense is the amount of "eligible" expenses you are expected to pay before your insurance covers the remaining "eligible expenses". Usually, this is a few thousand dollars. So lets say you pay $500 deductible and then have to pay co pays for some other health expenses - when the amount you have paid hits the Total out of pocket" the insurance will pay 100% of the rest of the eligible expense for the rest of the year.

The keys are

1. "eligible" - If your doctor charges $2000 for an operation and the insurance company feels that only $1600 is reasonable and they pay that - you owe the doctor $400 but when you pay him that $400 won't count toward your total out of pocket.

2. If you reach the total out of pocket on October 30th - only eligible out of pocket expenses for Novemeber and   December will be paid. My advice is to get your claims in promptly if you are near the out of pocket total.

Hope this helps.