This article is an original article from January 5, 2009. It was written by Nick Perry.
When you’re shopping for a health insurance policy, it’s easy to get overwhelmed by the sheer volume of information. Deductibles, copays, coinsurance, riders, exclusions, caps, and more — the list of things you need to know can be daunting. For that reason, I’ve compiled the following list of five questions you should always ask your agent about any health insurance policy you’re considering. When you’re on the phone with your agent trying to figure out which health insurance policy is right for you, asking these questions will give you a comprehensive look at the policy without swamping you in information you don’t need.
1. What’s the deductible?
This should be the first question you ask about any policy. The deductible is the amount of money that must come out of your pocket before your health insurance company will begin paying benefits. So, if you have a $500 deductible, and you get a $750 hospital bill, then your benefits will kick in on the last $250. That first $500 will be applied to your deductible.
Your deductible will have a massive impact on your health insurance premiums. Having a higher deductible will lower your premiums, and having a lower deductible will raise them.
Take care to note, however, that that doesn’t mean you’ll only have to pay $500 dollars and consider that $250 handled. Many health insurance plans have a coinsurance amount linked to an out-of-pocket limit. In fact…
2. What’s my coinsurance and out-of-pocket?
Depending on the company, the “out-of-pocket” limit may also be called a “stop-loss” or “break point,” but these things are all the same. Your out-of-pocket limit is the amount of money beyond your deductible that you’ll be responsible for before your plan pays 100% of your remaining medical costs. The out-of-pocket limit is always paired with a coinsurance amount, which defines what percentage of costs beyond your deductible you’ll be responsible for on any given bill. So for instance, if you’ve satisfied your deductible but have a $1000 out-of-pocket limit with an 80% coinsurance, and you get a bill for $100 dollars:
The insurance company will pay $80 of this bill and you’ll be responsible for $20 of this bill
And that $20 will be applied to your out-of-pocket limit, reducing the balance down to $980.
So, even though the bill was $100 dollars, you were only responsible for $20 because you had met your deductible. With these numbers, if you had medical bills (after your deductible) totalling $5000, you would be responsible for $1000 and the insurance company would pay the remaining $4000. Paying that $1000 would also cause you to reach your out-of-pocket limit, so any additional covered medical bills within your beneift period would be covered at 100%. Out-of-pocket limits are generally locked into various policies, so even if your agent can adjust the deductible it’s common that the out-of-pocket can’t be changed.
One important thing to note is that if you have a high deductible health plan, or HDHP, you usually won’t have an out-of-pocket limit. Once you meet your deductible, your costs will generally be covered at 100%.
3. Is the deductible per-incident, per-confinement, or per-year?
This one is huge. One of the sneakiest ways health insurance companies reduce their risk, and therefore lower their costs and raise their profits, is by defining their deductibles by confinement or incident instead of the standard per-year definition. With most health insurance policies, once you meet your deductible, you’ve met it for the year. Any further medical bills will be applied to your out-of-pocket limit, and then covered at 100% once that is satisfied. This means that if you have more than one incident in a year that causes you to incur significant medical costs, you’ll be covered.
However, if you have per-confinement or per-incident deductibles, things are very, very different.
With per-confinement or per-incident deductibles, every time you have a situation where you require medical attention is subjected to its own deductible. So if you have a $1000 per confinement deductible then have food poisoning in January, a broken arm in March, strep throat in June, a routine OBGYN visit in August, a case of the sniffles in October, and you cut your hand open carving the Thanksgiving turkey, then each one of these incidents is subjected to its own $1000 deductible!! In other words, say the total medical bills related to your food poisoning come out to $800, your broken arm is $750, the two doctor’s office visits together come out to $350, and then the ER visit for the Thanksgiving mishap comes out to $500. That totals up to $2400 in medical bills for the year, which means that $1000 should apply to the deductible and $1400 to the out-of-pocket limit, right? Nope — you’ve got per-incident deductibles, and not a single one of those visits cost more than $1000. That means that with each new medical incident your deductible reset back to $1000, and you never once met it. Every last dollar of those medical bills comes out of your pocket, because the deductible was per-incident, not per-year.
Long story short, deductibles should be per year, not per incident or per confinement, especially if you have more than one person on the policy. MEGA Life and Health is infamous for defining its deductibles by incident instead of by year. Golden Rule’s short-term medical plans also use per-incident deductibles, which is why they’re one of the cheapest short-term medical policies on the market.
4. Do I have an office visit copay?
When you go to the doctor, some insurance plans hold you responsible for the entire sum of the bill (subject to your deductible and coinsurance, of course) while others employ a copay. Basically, when you have a copay, you’re responsible only for a nominal fee to go see your doctor instead of the full bill. That fee usually hovers around $15-$35 for a primary care physician (a family doctor) and $25-$55 for a specialist (an orthopaedic doctor, dermatologist, OBGYN, or other, specialized doctor).
On the face of things, a copay sounds fantastic. Instead of being responsible for the entire cost of a doctor’s office visit, a copay reduces the cost to a predictable amount that is essentially always lower than the full bill. However, adding a copay to your insurance plan is the number two biggest thing you can do to increase your monthly premiums (number one is lowering your deductible). Think about this: how many times a year do you go to the doctor? Most people will say anywhere from one to three visits is average for them. The additional cost you would pay upfront for those one to three visits a year is almost always offset by the amount of money you’ll save off of your monthly premiums by switching to a plan that doesn’t offer an office visit copay. Let’s run the numbers:
The average cost of a primary care visit is $60; a specialist visit averages about $175
The average primary care copay is about $35; for a specialist, that’s about $50
So in a year that you went to your primary care doctor twice and a specialist once, you’d pay $120 on a copay plan or $295 for a plan that doesn’t offer copays. The difference there is $175, or a little under $15 a month. In this scenario, it makes sense that if you can save over $15 a month by eliminating copays from your plan, then it’s smarter to be without copays than to include them. I can say with a great deal of confidence that if two plans are identical in every way except that one offers a copay and one doesn’t, then the plan without a copay will always offer savings greater than $15/month in premiums.
If you’re really, really tied to having a copay, then consider asking your agent about a plan with a limited number of office visits covered by copays a year. Most limited-copay plans give you six or so office visits a year covered by a copay, and you’ll be responsible for the full bill after those visits until you meet your deductible. These plans give you a compromise by lowering your premiums but still giving you the comfort of the copay.
5. Do I have a limited period to get diagnostic tests?
After the per-confinement deductible, this is the worst trick an insurance company can pull. With most plans, diagnostic tests can be done at any time so long as they’re medically necessary. This means that if you think you’ve broken your hand, you go to the doctor, have an x-ray, and then find out that you’ve just bruised it, well, no big deal. That x-ray was deemed medically necessary by your doctor, and therefore it was a covered expense.
This changes, however, with some types of health insurance plans. Certain plans allow diagnostics only in a certain time period before and after a surgical procedure or inpatient confinement. For instance, some MEGA Life and Health plans allow diagnostics only fourteen days before and/or fourteen days after a surgery or inpatient confinement. This means that, in our example above, the x-ray would not have been a covered expense because no surgery resulted from it.
That limited window for diagnostics can be a minor pain when dealing with things like hand x-rays, but it can be absolutely devastating when dealing with monitoring a long-term condition like leukemia, or monitoring recovery after major surgery. You have health insurance to cover medical costs, so why would you accept a plan with such a fundamental limitation?
These five questions will give you a great deal of information about your plan by covering the basics (copay, out-of-pocket, and deductible) and will make sure you catch it if the policy includes one of the two most common sneaky limitations (per-confinement deductibles and diagnostic windows) that insurance companies use to limit your benefits. When I sit down with a client, these are always the first five things we go over, because I know that these five points are the most important things they could ask me to make sure they’re getting the level of coverage that they need.
The next thing you need to do is to ask yourself this: could I answer all five of these questions about my own policy? If you can’t, call your agent! Knowing the answers to these five questions will put you well ahead of the game and will keep you from being caught off guard by medical bills that you thought would be covered by your health insurance.