Health insurance coverage is a complex field and I'd like to take a few moments
on this video to explain to you some of the common terms used in health care coverage,
as well as walking through a specific example of how you might calculate
your out-of-pocket patient liability. So let's talk about some of the terms. First,
the insurance is your insurance that you have selected or has been selected for you. Aetna,
Anthem, Medicare, there's a variety of health insurances, including all of the ACA coverages.
Deductible is the amount you owe either annually or per visit for your coverage. That deductible
can vary wide widely across your payer plan and could be owed as many times as every time you're
an inpatient or is an annual deductible. You need to check into your coverage to understand your
deductible liability and how much that is. Copay is what you owe per visit. The most common copay
is for a doctor's office visit. You might owe a $10 or $35 copay every time you come in for a
visit. Coinsurance is a percentage of the allowed amount that you owe for that visit. Coinsurance
can vary widely and you really need to understand your particular coinsurance. You could owe 10%,
20%, as high as 40% coinsurance for that visit that you're having done and that coinsurance
is calculated on the insurance allowed amount. The insurance allowed amount isn't the charge,
it's how much the insurance company has agreed to pay your provider for those services. You
need to understand what that number is. You can usually get that from your insurance
company as well as often from your hospital or provider. Your out-of-pocket max is how much,
let's think of that catastrophically, that you could owe the entire year. In this example, this
person has a $3,000 individual out-of-pocket max and a $6,000 family out-of-pocket max. Critical
numbers to understand all of these before you have your procedure done. So let's walk through
this specific example and how it's calculated. So this is an MRI, an MRI let's say of the shoulder,
and the patient has ACME insurance. They have a $500 deductible for their individual and $1000
family deductible. They've met $200 of their individual deductible and $900 of their family
deductible. There's no copay for an MRI for this insurance company and their coinsurance is 20%
of the allowed amount. In this case, that's $240. The out-of-pocket max for this plan is $3,000 for
the individual or $6,000 for the entire family and they've met $200 and $1,000 respectively of that
for the family. So now let's walk through what this person is going to owe for this
MRI on this date. So on the deductible, they're going to owe $100 because the family deductible
is closer to being met. All they're going to owe for their deductible is $100. On the coinsurance,
the 20% of the allowed, they're going to all $240. So that means for this MRI, this patient
is going to owe $340 dollars for the services provided on that date of service. Of course
this is an estimate. You could come in and have something else done on that date of service or
you could change what you owe and your deductible between now and when your services are provided.
Do your homework before you have a procedure done. Understand what you are going to owe,
what your responsibility is. Go in as an informed consumer and you will have fewer surprises.