Quick Health Insurance Question

[RainMaker]

I recently had a trip to the ER. Now my plan has a $150 co-pay to it which I paid on site. Now do I still have to pay for things up to the deductible? Or does the co-pay cover the visit in full. I can't really find any information on that online. It seems like they're separate as I've never had to pay for stuff that went on at doctor visits that had a co-pay, but what do I know?

Complicating things further is apparently this hospital doesn't take my specific health insurance for some reason (it used to). So I'd technically be out-of-network. Not sure if that matters though with ER visits.

Any help is appreciated.

[terpkristin]

It depends.

If you have a deductible and they cover the services, then yes, you will likely have to pay the deductible (in addition to the copay) assuming you haven't hit your out of pocket max for the year.

My insurance has a $100 copay for ER visits (they want to encourage use of Urgent Care), plus a $200/year deductible for hospital visits plus $200/year deductible for outpatient facility (like PT) visits plus 90% coverage until I hit my out of pocket max for the year.

So if I went to the ER today, I'd owe $300, plus 10% of the (reduced-price) costs.

Of course, if my insurance coverage had been the same last year as this year (last year I had 100% coverage, not 90%), I'd have hit my out of pocket max before paying out even a quarter of the 10% of the hospital/surgeon fees. Yipes.

/tk

[RainMaker]

So I'm looking at a decent bill in the mail? I have like a $2000 deductible I think. Might be higher out of network.

[flere-imsaho]

terpkristin has it right.

Depending on where you went, you should now expect several different bills over the course of the next few months for your treatment, all of which are likely to be proceeded by EOBs from your insurance company, which will look like bills, but will not be bills (read them carefully). If done correctly, the EOBs will give you an idea what you'll end up paying to various providers after your insurance rates are factored in (i.e. it'll show you the "retail" price, and then minus the discount for the insurance, if that makes sense).

It should be better (paperwork-wise) if you went to Advocate, worse if you went to NorthShore (though the quality of the treatment in either location would have been excellent).

Good luck!

[flere-imsaho]

Originally Posted by RainMaker

So I'm looking at a decent bill in the mail? I have like a $2000 deductible I think. Might be higher out of network.

Yeah, you're looking at several bills, and it'll probably add up to a good bit, but you probably won't see the first actual bill for a month or so. You should see at least one EOB before then.

[RainMaker]

I looked through my past payments and I actually had an ER visit back in 2009. I only paid $200 co-pay. It's the same insurance I guess so I'm not sure how I got off the hook back then.

[RainMaker]

Also when I go to the doctor it's a $25 co-pay or whatever and I never get billed for other stuff.

[MacroGuru]

Well, a lot of plans changed with the ACA, my deductible shot up to 600 / 1200.

I am getting ready for surgery here in less than 3 weeks. My initial visit, CT Scan and Surgeon appointment all went through to my deductible. So I am right now owing right around $550 to the 3 dr's. I am only $50 away from my individual deductible which means I will be fine and everything else will be paid in full except for $50. So this surgery which will probably cost a lot isn't going to hurt me as much as I thought it would.

[TRO]

Originally Posted by RainMaker

Also when I go to the doctor it's a $25 co-pay or whatever and I never get billed for other stuff.

Your plan is most likely covering 100% of preventative services.

Regarding ER visit, you will likely be looking at your copay + deductible + your coinsurance up to your out of pocket max.

When figuring your out of pocket max, your copays are not included in the total.

[flere-imsaho]

Originally Posted by RainMaker

I looked through my past payments and I actually had an ER visit back in 2009. I only paid $200 co-pay. It's the same insurance I guess so I'm not sure how I got off the hook back then.

I would guess you had reached your deductible by that point, and/or out of pocket max.

It depends on a lot of factors.

You seem to keep a good handle on your bills, so I wouldn't worry about it.

[PilotMan]

Originally Posted by RainMaker

I looked through my past payments and I actually had an ER visit back in 2009. I only paid $200 co-pay. It's the same insurance I guess so I'm not sure how I got off the hook back then.

I think that the insurance companies have changed how they cover things. I used to have $100 co-pays back when by boys used to like to make their heads bleed, typically that was all I'd ever see.

Reading the fine print on my current policy (different co) have $150 co-pay, then deductible, then 80% coverage after that.

So you may be right, but you may be getting more bills too depending on what other services you received.

[BYU 14]

Depends what type of plan you have (HMO, PPO, EPO, ACA, EPO). It can vary drastically by plan type. An HMO for example would only hold you liable for the copay in network and could have either a higher copay for out of network facility, or the same copay, or charge deductible, but it would have to provide at least some coverage for out of network emergency services, which is consistent among all plans.

The key factor here is the ER you used is out of network, so you will likely have increased out of pocket cost regardless of how the benefits are administered. What type of plan do you have and who administers it?

I have been in the health insurance field for 24 years, so shoot me a PM if you like and I can help further with some additional information.