TAKING THE CONFUSION OUT OF YOUR INSURANCE BENEFITS

Copays, deductibles, and coinsurance, OH MY!  Trying to understand insurance benefits can be very difficult and overwhelming at times.  In an endeavor to help you better understand the commonly used terms and abbreviations, we have put together the following so you can spend more time focusing on your health and feel more prepared when planning your care as it relates to your out-of-pocket costs at Pain Care.

A copay (or copayment) is a flat fee that you pay each time you go to your doctor.  Your insurance card will typically show your copay.  At Pain Care, you will owe a Specialist OV copay for your office visits.  It is possible, even with a flat copay for your office visit, that your lab work at Pain Care may be subject to your deductible.  

A deductible is the amount you pay each year for most eligible medical services or medications before your health plan begins to share in the cost of covered services. For example, if you have a $2,000 yearly deductible, you'll need to pay the first $2,000 of your total eligible medical costs before your plan helps to pay.  If your insurance card shows a $0 specialist copay, chances are you have a deductible-first policy.  

Coinsurance is a portion of the medical cost you pay after your deductible has been met. Coinsurance is a way of saying that you and your insurance carrier each pay a share of eligible costs that add up to 100 percent.  For example, if your coinsurance is 20%, your insurance carrier will pay 80% of your costs and you will pay 20%.

Out-of-pocket maximum is the most you could pay for covered medical expenses in a year. This amount includes money you spend on deductibles, copays, and coinsurance. Once you reach your annual out-of-pocket maximum, your health plan will pay 100% of your covered medical and prescription costs for the rest of the year.

EOB is an abbreviation for Explanation of Benefits.  This is the notice you will receive from your insurance company after your doctor bills for a medical service, explaining what was paid to your doctor and what you may owe. 

COB is an abbreviation for Coordination of Benefits.  This applies only when you have two or more insurance policies and relates to which insurance plan has the primary payment responsibility.  The insurance companies decide this based on employment status, age and sometimes health conditions, so it is very important for you to contact all your insurance carriers to make sure this is updated. 

Always contact your insurance carrier if you need clarification regarding your coverage and benefits; however, we have knowledgeable and caring financial counselors and billing staff who are always available to help you with any questions and concerns related to your medical costs. 

How do I decide what insurance plan to choose?

If you are mostly healthy and don't expect to need costly medical services during the year, a plan that has a higher deductible and lower premium may be a good choice for you.

On the other hand, if you know you have a medical condition that requires more medical care, a plan with a lower deductible and higher premium that pays for a greater percent of your medical costs may be better for you.

References:

In-network vs. out-of-network providers. Cigna. (n.d.). Retrieved January 25, 2022, from https://www.cigna.com/individuals-families/understanding-insurance/in-network-vs-out-of-network

Written by Patty, Senior Billing Liaison with Pain Care
Published by Casey, Business Development Coordinator with Pain Care