A traditional health insurance plan operates on the system of copayments (copays) and coinsurance. You will pay a monthly premium for the coverage. In addition you will pay a copay for every doctor visit, as well as trips to the hospital and emergency room. The copays are set, and usually increase when you see a specialist or go to the emergency room.

You may also be required to pay coinsurance on certain procedures such as tests or hospital stays. The coinsurance is the percentage of the bill that you are responsible for in addition to the copayment for the procedure. For example is you have 80/20 coinsurance, the insurance company will pay eighty percent of the cost and you will be responsible for the other twenty percent. This coinsurance applies after you have reached any deductible set by your insurance policy.
Many policies have a maximum out of pocket payment limit. Once you reach this limit the coinsurance no longer applies, although you do need to continue to pay your copayments. You will also pay coinsurance on the amount that your insurance has contracted to pay for procedures with the hospital and doctor. For this reason it is important to pay attention to both your doctor’s bills and the insurance statements that you receive outlining the payment amount.

It is important to understand how much a procedure could cost you. For example if you had to undergo surgery and stay overnight, you would have to pay your hospital copayment amount, pay the deductible amount if you have not already met it, and then pay your coinsurance amount on the remaining balance of the bill. You can call and talk to a representative at your insurance agency to learn the estimated costs of the procedures before you have them done. Additionally you should make sure that you get preapproval for most tests and surgeries before you have them done. This is one reason why it is very important to go with a reputable insurance company and not a discount plan.  Most hospitals work with all the of the major insurance companies therefore they will already know what is covered and not covered.

The “it” is any type of usual and customary healthcare costs. Why should this be so difficult? I am not specifically talking about large catastrophic costs. A heart surgery is going to be expensive no matter what. Cancer treatment is also going to be expensive at any hospital. Also, these are conditions or ailments that need to be treated to a large extent regardless of the cost.

Yet, outside of catastrophic medical care, our basic healthcare services; primary care visits, specialist visits, diagnostic services, MRI’s, x-rays, blood tests, physicals, stress tests, EKG’s, etc. are a big mystery to really, most of us. We simply are not able to get from providers what these services cost as easily as we would any most other services in our economy.

Why? Why aren’t these services advertised and promoted freely so we can all know what they cost. As consumers we understand quality and cost. We just simply want to know ahead of time how much is it and for what?

Don’t attempt to sneak cost line items and services we did not receive into our bills.

We are American consumers that do not want things for free, but we want to make good decisions when it comes to our healthcare services. Some of us may want to go to a doctor who charges lower prices for their services than another doctor who also has more expensive magazines in their waiting area.

One doctor may bill you for 30 minutes worth of a visit even though they actually consulted with you for only ten minutes. Why?

All we want is clarity.

The result to all this confusion is part of the reason of why we tend to be so fixated on our health insurance plans covering for these services (co-pays, doctor visits, specialists, deductibles, etc., since we simply don’t understand these costs.

As Americans, we want our highly trained and specialized doctors to earn a good living. These individuals are highly respects and rightfully so for their hard work and intelligence. Yet, all we want to know is how much it costs?

Co-Pay is the portion of the medical bill that you the policy holder is responsible for when medical services are rendered by a physician, these co-pays are pre-set dollar amounts.

Insurance companies offer unlimited, limited and no co-pay doctor office visit depending on the type of plan that you are purchasing. Typically a plan with limited or a pre-set number of office visits are lower priced when compared to plans that offer unlimited office visits. There are plans that do not require you to meet your deductible before using the co-pay benefit at the doctor.

When to purchase unlimited vs. limited or no co-pay plans? A healthy individual that visits a physician twice a year or less would save money by purchasing a plan that offers no co-pays or limited co-pay office visits, a family with children would benefit by purchasing a plan with unlimited doctor office visits, children are more prone to getting sick, injured and will visit doctors more often during the year. Adults with children will also be more prone to becoming sick so a plan with unlimited doctor office visits would be beneficial in the long run.

Why get hung up on Copay’s only?

Many clients buy health insurance and rate insurance carriers by the doctor office copay amount offered rather than by what type of coverage the plan offers, what is the maximum amount covered, what coverage area the plan offers, what is excluded in the plan, what rating the carrier has and how much risk are you willing to accept.

The option to offer doctor office visit copay’s is not a benefit that is free of charge to you, the policy will have a monthly added cost to cover such benefits and the carrier knows that a healthy individual might visit a doctor one or two times a year, this option usually doesn’t benefit the policy holder.

Health insurance should be purchased based on the following:

1) Type of plan being offered (PPO / HMO / POS)

2) What is covered by the plan, what is not covered by the plan.

3) What is your maximum out of pocket expense with the plan.

4) How much money are you willing to risk if you become ill.

5) Are you covered outside of their network, do you need referrals for specialists.

6) What capacity does the carrier have to pay claims (A.M. Best Rating).

7) What premium can you afford on a monthly basis without having to lapse the policy.

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