This article is not all inclusive and is meant to explain the basics of how most USA health insurance policies work in regards to your out patient care appointments. You will need to look at your individual policies for confirmation and details where your policy may differ from the general description below.
First you choose a health insurance policy.
Most of the policies presently consist of a premium, a deductible, and co-pays.
Premium is the amount you pay every month to the company to be able to have a month to month policy. If you don’t pay this premium, they can cancel your insurance. If your premium is $250/month, this will cost you $3000 per year whether or not you use your insurance and does not apply to your deductible.
Deductible is the annual amount set up by the company that you/your family must pay before the company pays out any substantial payments to your providers. For example, you have a $5,000 deductible. You must pay the first $5,000 of medical services before the company pays. Depending upon your policy, there may be some visits that are covered before the deductible is met such as annual physicals, but that will vary from policy to policy. Otherwise, you are responsible for covering office visits, labs, and procedures up until the deductible is met.
Co-pays are paid at each office visit in accordance with your plan’s policy. Not every policy requires this, but most do and it is applied to your deductible.
What happens when you are seen in the clinic and you have not met your annual deductible?
The clinic takes your co-pay, which the company will apply to your deductible. It is illegal for any clinic to not collect a co-pay if your insurance requires you to pay one, so please do not ask for the clinic to waive your co-pay. If you do not pay your co-pay at the appointment, insurance requires you be billed for this and you are responsible for this amount, not your insurance.
At the end of the visit you have the option to pay then or be billed.
Paying at time of service often gives you a discount with the clinic, ask if this is possible. You should receive a receipt and a billing slip which will allow you to send to your insurance company for reimbursement. The funds you paid for your visit are then applied to your annual deductible.
If you are to be billed, the clinic will submit the bill to your insurance first. If you have not met your deductible, the insurance company will notify the clinic and then the clinic must send you a bill for that visit. If you have met your deductible, the insurance will send a portion of the clinic fees as their payment to the clinic, and then the clinic must bill you for the remainder. Typically, many insurances use an 80-20 split. They pay 80%, you pay 20%. This varies from policy to policy and you must always know your own policy to know for sure what your coverage is and what amounts you will be responsible for.
If you are receiving care at a cash only clinic, i.e. one that does not accept insurance, the process is the same as if you were choosing to pay cash instead of billing your insurance up front: you pay the clinic, they give you a receipt and billing slip for you to submit to your insurance company, and then your insurance company reimburses you. Best to confirm with your insurance prior to your visit to make sure they will cover the care.
Those with this type of insurance do not have a deductible. Medicare and Medicaid only pay to clinics that are signed up with these insurance plans. Cash only clinics are not in this group. If you have Medicare or Medicaid you may use a cash only clinic and pay the clinic, but you will not be reimbursed from the insurance company.
Some people choose to get care at a cash only clinic even though they have insurance if the clinic offers services their own PCP doesn’t or if they prefer the provider(s) in the cash only clinic. If they have insurance that is not Medicare/Medicaid, these visits may be reimbursed by their insurance companies and applied to deductibles. This is money that you would need to pay to the clinic taking insurance anyway if your deductible was not met. So, this can potentially not cost you any more to use a cash only clinic.
If you have an HMO such as Kaiser Permanente, you must get all your care through the HMO unless there is a written agreement/contract between the HMO and your chosen non-HMO provider. You will need to discuss using a non-HMO provider with your HMO prior to seeking care outside the HMO if you want to be reimbursed for care outside the HMO.
This information is provided to help potential patients in our clinic since some of the providers are cash only and do not take insurance. Some providers do take insurance but recall from the explanation above, you may still be billed for the visit if your deductible is not met. If you have questions about your policy, always review your policy or talk to your insurance representative.