There are thousands of insurance plans out there and it is impossible for us to know what coverage you have based on the limited information that is available on your insurance card. It is ultimately the patient’s responsibility to know what their coverage is, the same as it is a credit card holder’s responsibility to know what interest they are paying. It is a contract you have signed with your insurance agreeing to pay your deductibles, co-pays and co-insurances.
Generally, you pay insurances so they will pay for your medical visit. To keep costs down for the member, an insurance will apply deductibles, co-pays, and/or co-insurances. They end up paying less for your visits at a lower cost to you. A lot of insurance plans will offer lower co-insurances and co-payments the more you go to the doctor throughout the year. Your benefits reset every year, but the month it resets is dependant on your plan. Medicare, for example, resets the first of the year. So if you have met your deductible for 2015 and your plan resets January 1, your insurance will start applying the new deductible January 1.
It is possible for your insurance coverage to apply a deductible, co-pay, and a co-insurance all at the same time. This is where insurance gets really confusing.
Your co-pay is $20.00.
You have a deductible of $100.00 per year.
After your deductible is met, your insurance will cover your remaining visits for the year at 75%.
Your insurance approves your visit for $500.00
Your insurance pays $285.00 and you are responsible for the $20.00 co-pay, the $100.00 deductible and also $95.00 co-insurance.
500 – 20 copay = 480
480 – 100 deductible = 380
380 x 25% co-insurance = $95.00 – patient’s share
380 x 75% = $285.00 – insurance’s payment
You end up paying $215.00 and your insurance pays $285.00.
However, on your next visit, you will not have to pay your deductible because it has already been satisfied in your first visit. You will only be responsible for your co-payment and co-insurance.