medical bills help

[tcat216]

This may sound dumb but I need someone to explain how one pays medical costs with insurance deductibles and coinsurance. I have never been sick enough to have to go to the hospital or even just to the doctor. The last time I was injured was when I broke my leg as a teenager so my mom paid that. So I have never had medical bills before.

I was wondering when you have to pay a deductible do you pay that at the time of service or are you billed for it? If for example, my deductible is $500 and my insurance pays 70% of hospital bills what would I have to pay at the hospital, if any, and what would I be billed for?

Also for those of you who gave birth at a birth center and used insurance, is it handled the same way as a hospital would or do you have to pay the amount you are responsible for before you give birth like you would if you were paying cash?

Thanks for the help. I feel embarrassed having to ask this on a message board but I have zero experience with medical bills.

[happysmileylady]

No reason to be embarrassed, the reality is that insurance and payments and such can be SO confusing and most people have a hard time figuring out how their insurance coverage works.

Generally speaking, when you are insured and need medical care, you go to the care provider,and they take a copy of your insurance card. They provide whatever care it is you need-ER visit, maternity, whatever it is. When it's all done, they submit the bill to the insurance. The insurance then pays whatever you are covered for, then informs the provider. The provider will then send you a bill for the portion you are responsible for.

The thing is, it can be difficult to figure out just what you will be responsible for ahead of time. It's not always so straightforward as just having a $500 deductible and then coverage at 70%. With different policies, different things are sometimes covered at different rates, like preventative care being covered at 100%. Then you run into the issues of what is considered "preventative" and what isn't. Likewise, some things might not be subject to the deductible. And then, some things might have a specific co-insurance, separate from the deductible that might be due at the time of service. Those are usually things like a doctor's office visit or prescriptions.

In reality the answers you are looking for are likely specific to your particular insurance policy, so you probably want to call your insurance company and talk to someone there.

[VinhThiMom]

All policies are different. Some things do not require you to pay your deductible. For example, my insurance has been billed $80k this year for me and I've only had to pay $150 of my deductible plus 20% of the negotiated rate (not the billed amount). My deductible is only $300, but I've spent $3k out of pocket because coinsurance (my 20%) doesn't apply to the deductible. I also have a max out of pocket ($3k) so after that, stuff is covered 100%.

As for when you pay, that depends on the provider. If its a planned procedure/surgery/visit, it gets pre certified (provider contacts insurance) and I have to pay when I go in for the procedure.

[JeDeeLenae]

I think if its pregnancy related, a lot of times they'll get an estimate from your insurance company of what you have to pay. Lets assume you have this:

$500 deductible
$3000 out of pocket maximum
70/30 insurance coverage after deductible
Birth center charge is $5000

You have to pay $500 of that which leaves $4500.
Insurance covers 70% of $4500 = $3150
You are responsible for 30% of $4500 = $1350
$1350 + $500 = $1850 patient responsibility.

They'll take that figure and spread it across your care, usually up to your 28th or so week, so say you have 9 appointments left until then, so you make $205 payments.

Not all places will do that though. Your birth center might require a deposit or pay by 34th week or whatever.

But, for a hospital operation, they will usually bill you for the portion you have to pay or require the deductible upfront.

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