US health insurance: difference between deductible and co-pay?

[Mdcastle]

Just to make sure we have out terms straight here:
Copay: A flat amount to be paid per visit. ($20.00, $30.00, etc) Usually but always it starts after the deductible has been met, and it may or may not stop when the out-of-pocket max has been met:
Coinsurance: A set percentage of the total allowed amount (10%, 20%, etc.) pulled after the deductible has been met, to be paid until the out-of pocket max has been met

[Really_Not_All_That_Bright]

“Usually but always”?

@leahcim

Note that the savings aren’t nearly as great as that makes it seem. The “full” price is pretty much an artifact – almost no one pays it, not even the uninsured who usually work out some kind of deal. The “full price” is large so the insurance companies can present that they’re getting such a great 90+%-off deal for their clients.

Not quite. The pre-fee schedule rates are high so that hospitals can get a contracted rate from the insurance companies. It’s a negotiation tool: “well, our normal rate is $x, and usual and customary is $y, so how about we split the difference for you?”

Either way, of course, the figures have virtually nothing to do with the actual cost of providing the service.

[Northern_Piper]

Thanks for the explanations and examples, everyone. It’s all very illuminating, and makes me give thanks to the shades of the trio of Tommy Douglas (socialist), Emmett Hall (conservative) and Mike Pearson (liberal), who together gave Canada our single-payer system of medicare.

[alphaboi867]

@doreen

Sometimes- there are some HMOs that have a network of independent providers and facilities which have contracts with the HMO (like a PPO) , but the HMO pays nothing if you go to an out of network provider/facility

Unless you go to an ER then (subject to medical necessity) the insurer will pay as if it’s in-network. Unlike HMOs PPOs provider two sets of benefits; in-network & out-of-network. For example my insurance pays 80% once the deductible is met if I go to an INN provider, but only 50% if I go to an OON provider. Also my OON deductible is higher & there’s no out-of-pocket cap like there is INN.

@MsRobyn

…It’s also not a safe assumption that insurance will always pay a claim. Using the above as an example, let’s say that Medicare denied Patient A’s x-ray as not medically necessary. Patient A is now on the hook for the $50 unless Dr. Radiologist’s staff can justify re-billing it with a different diagnosis. (This happens a lot in radiology, defensive medicine being what it is.) So by billing everyone $50, the radiologist can collect the full fee if the insurance denies the claim; if the radiologist had only billed the $5 he knows Medicare will pay, he’d only be able to collect the fiver.

Many insurance policies require providers to call the insurance company in advance to her authorization for radiology procedures. Depending on the policy an in-network provider who doesn’t do this may have to eat the cost themselves if the claim is denied (ie they can’t make the patient pay). An out-of-network provider wouldn’t be subject to any such restrictions.

[doreen]

@alphaboi867

Unless you go to an ER then (subject to medical necessity) the insurer will pay as if it’s in-network. Unlike HMOs PPOs provider two sets of benefits; in-network & out-of-network. For example my insurance pays 80% once the deductible is met if I go to an INN provider, but only 50% if I go to an OON provider. Also my OON deductible is higher & there’s no out-of-pocket cap like there is INN.

I wasn’t talking about a PPO- I was talking about an HMO which resembled a PPO in one way only - the facilities were not owned by the HNO and therefore the providers were not employees of the HMO . It paid nothing if I saw a non-participating provider ( except possibly an ER), I needed authorization from my PCP to see a specialist, all of that.

[usedtobe]

@Terr

Not according to the Exchange web site in my state (MD). All the plans that have deductibles specify stuff like “20% (after deductible)” for drugs or doctor visits.

I think I found out where the discrepancy we see lies:

Coveredca has changed the format of the benefit summary - no more black (exempt from deduct.) and blue (subject to deduct.) fonts - you now click on a category and it pops up the co-pay and, optionally, “after deductible”)

The new format makes it more obvious:
Whether it is or isn’t subject to a deduct is one of the parts of the subsidy. I may be seeing a better level of subsidy based on income and disability.
Play with the numbers and see if you can get it remove the “subject to deductible” tag on various categories.

It also says that a full application is required to make a final determination of benefits.