Discounted Rate Procedures/Benefits.

[J.R.]

Would anybody be able to clarify the following for me?

Client A has a mid-level deductible (say $2000) plan, 80/20 co-insurance, $20 co-pay for physician visits and a $5000 deductible for maternity w/ covered expenses @ 100%.

When the insurance carrier receives a bill for client A visiting the doctor the bill will be repriced to reflect the discounted rate if it is a covered expense. Is it possible for client A to receive the discounted rate that the insurance company would get if Client A did not have the $20 co-pay (paid all of the money upfront herself) feature or if the procedure was not a covered expense (i.e., Client A gets pregnant and did not have the aforementioned maternity benefits)? Thanks.

 

[somarco]

If the doc visit is a covered expense the repriced rate would prevail assuming the client uses a par provider. In addition, the amount paid for the doc visit would accrue towards satisfying the deductible . . . something that does not occur when one has a copay.

If the policy does not have maternity benefits there is no repricing.

 

[Crabcake Johnny]

And maternity is a good topic since not only isn't there re-pricing but also no stop-loss if they happen to get pregnant without coverage.

Not everything is a normal pregnancy. My wife had many complecations during her pregnancy and a nightmare birth with complications after the birth. I can't even imagine what they bill would have been.

A lot of agents don't like discussing maternity. Bad move. Most clients think it's included - especially clients who are used to group coverage. Other clients may assume it can be added. In Maryland maternity can never be added after the policy is issued.

 

[Dave020]

Interesting, in California the carriers offer a switch-over to a maternity included plan if the subscriber becomes pregnant and has a no maternity plan. Most go over to a $5000 deductible PPO plan from whatever plan they had and there is no underwriting for this change.

Dave