Question About Co-pays and Deductibles...

Hedgehog25

New Member
6
I am a 26 year-old male who was recently booted off his parents' insurance plan, so I've been perusing the various insurance plans available via the ACA exchange as well as BCBS's website (whose plans still cover the rest of my family). I have a question regarding co-pays and deductibles. What does this statement, as one particular example regarding primary care visits to treat an injury or illness, actually mean: "you pay $40.00 - not subject to deductible, for the first 2 visits. For additional visits you pay 20% after deductible." For the plan that included the quoted statement, the deductible is $5,750.

Does that mean that for the first two visits to the doctor's office, I will only pay $40 and that's it? And then from the third visit onwards, I will have to pay my medical bills in their entirety out-of-pocket until I have paid the deductible of $5,750? And then at that point, I will only have to pay 20% of each medical bill?

And what if I have a pre-existing condition that requires regular visits to, say, an endocrinologist? How much would I end up paying for each visit?

Something tells me I'm assessing this completely incorrectly -- advice would be greatly appreciated!
 
I am a 26 year-old male who was recently booted off his parents' insurance plan, so I've been perusing the various insurance plans available via the ACA exchange as well as BCBS's website (whose plans still cover the rest of my family). I have a question regarding co-pays and deductibles. What does this statement, as one particular example regarding primary care visits to treat an injury or illness, actually mean: "you pay $40.00 - not subject to deductible, for the first 2 visits. For additional visits you pay 20% after deductible." For the plan that included the quoted statement, the deductible is $5,750.

Does that mean that for the first two visits to the doctor's office, I will only pay $40 and that's it? And then from the third visit onwards, I will have to pay my medical bills in their entirety out-of-pocket until I have paid the deductible of $5,750? And then at that point, I will only have to pay 20% of each medical bill?

And what if I have a pre-existing condition that requires regular visits to, say, an endocrinologist? How much would I end up paying for each visit?

Something tells me I'm assessing this completely incorrectly -- advice would be greatly appreciated!

Hedgehog,

Not completely incorrectly. You are correct about the basics. The plan you are quoting would charge you $40 for the first two visits. After that, the deductible kicks in (this is the same deductible that would affect imaging, hospital stays, ER visits, etc.) Once you have reached the deductible, your office visits would be 20% of the price agreed upon between the insurance company and your doctor. Unless the plan specifies a different scale for specialists, this would apply to either your PCP or the endocrinologist.
 
Hedgehog,

Not completely incorrectly. You are correct about the basics. The plan you are quoting would charge you $40 for the first two visits. After that, the deductible kicks in (this is the same deductible that would affect imaging, hospital stays, ER visits, etc.) Once you have reached the deductible, your office visits would be 20% of the price agreed upon between the insurance company and your doctor. Unless the plan specifies a different scale for specialists, this would apply to either your PCP or the endocrinologist.

Thanks. So if I'm going to be going to the doctor every 6-8 weeks, I would most likely be better off with a plan that doesn't require the deductible to be paid after the first few office visits?
 
Thanks. So if I'm going to be going to the doctor every 6-8 weeks, I would most likely be better off with a plan that doesn't require the deductible to be paid after the first few office visits?

Definitely. If you're going every 6-8 weeks, I would look at a silver or possibly even a gold plan. What state are you in? I'm sure there's a broker here who could help you.
 
Definitely. If you're going every 6-8 weeks, I would look at a silver or possibly even a gold plan. What state are you in? I'm sure there's a broker here who could help you.

I was just looking over some of the different plans on the online ACA exchange, and I have a question regarding some of the information presented under the "Copayments/Coinsurance" headings for certain plans:

"Copayments/Coinsurance
Primary Doctor: No Charge after Deductible
Specialist Doctor: No Charge after Deductible
Generic Prescription: No Charge after Deductible
ER Visit: No Charge after Deductible"

Does all of that mean that regardless of whether I'm seeing a primary doctor, specialist doctor, filling a prescription, or going to the ER, I'm responsible for paying 100% of all my bills until I reach the deductible amount (which, in this case, is $6,300)?

But if that's the case, then what would the statement "Doesn't apply to preventive care and prescription drugs" (found in the benefits summary) imply? Does that mean that I would be able to visit, say, an endocrinologist to have routine lab work done, and then pay a co-pay instead of having to pay towards the deductible? Or would it mean that whatever I have to pay to the endocrinologist would not count towards my deductible?
 
Almost all Georgia plans on the exchange are HMO's with limited networks. All Blue plans, on and off are HMO's.

If you are seeing a doctor, or doctor(s) you should be more concerned about par docs than copay's.
 
Almost all Georgia plans on the exchange are HMO's with limited networks. All Blue plans, on and off are HMO's.

If you are seeing a doctor, or doctor(s) you should be more concerned about par docs than copay's.


Thanks for pointing that out. Every time I tried to actually sign up for a new account, I was presented with the "please wait" page, but when I browsed through some of the silver/gold plans, I found a plan from Humana that sounded pretty good (the Humana National Preferred Gold 2500/3500 plan). All of the physicians I have ever gone to (or might go to in the future) participate in the plan, but here's the issue: it sounds like physical therapy services would have to be paid entirely out-of-pocket by me until I have paid the value of the deductible.

From what I could gather by browsing a number of plans, it seems like the vast majority don't cover PT appointments (until after the deductible has been paid, of course). Does anyone know if this is the case with the majority of plans, including those offered as well as as those not offered within the ACA exchange? Or, to ask it another way, should I just expect to have to pay out-of-pocket for any PT services from here on out?
 
I have one other quick question regarding plans on the ACA exchange. I noticed that most of the Catastrophic/Bronze plans state that "X" copay (often for both primary care docs and specialists) only kicks-in "after" the deductible. Does this mean that for one of those such plans, I would pay 100% of my medical bills until I spend the deductible amount, and then at that point, I would be able to pay just the co-pay? If so, would I also be responsible for paying the costs of basic primary care/specialist office visits if I have not yet reached the deductible amount?

I'm under the impression that this is the case, but several family members are arguing that I'm wrong; instead, they're insisting that primary care/specialist office visits aren't subject to the deductible and that they would be covered by the insurance company without me having to pay. They're claiming that I would only have to pay towards the deductible if I actually have a procedure done (e.g., surgery).

So who's correct here? I ended up going with a Humana National Preferred Plan that costs around $204/month, and I mainly chose it because it seems to have a thorough network of participating physicians and only requires a co-pay to be paid for both primary and specialist doctor's office visits (deductible doesn't have to be met first). Should I have gone with a plan that offers a lower monthly premium instead?
 
I have one other quick question regarding plans on the ACA exchange. I noticed that most of the Catastrophic/Bronze plans state that "X" copay (often for both primary care docs and specialists) only kicks-in "after" the deductible. Does this mean that for one of those such plans, I would pay 100% of my medical bills until I spend the deductible amount, and then at that point, I would be able to pay just the co-pay? If so, would I also be responsible for paying the costs of basic primary care/specialist office visits if I have not yet reached the deductible amount?

I'm under the impression that this is the case, but several family members are arguing that I'm wrong; instead, they're insisting that primary care/specialist office visits aren't subject to the deductible and that they would be covered by the insurance company without me having to pay. They're claiming that I would only have to pay towards the deductible if I actually have a procedure done (e.g., surgery).

So who's correct here? I ended up going with a Humana National Preferred Plan that costs around $204/month, and I mainly chose it because it seems to have a thorough network of participating physicians and only requires a co-pay to be paid for both primary and specialist doctor's office visits (deductible doesn't have to be met first). Should I have gone with a plan that offers a lower monthly premium instead?

There are plans that require you to meet the deductible even with your PCP before you start getting copays. This does not include preventative visits (annual, screenings, vaccines) which must be covered as an essential health benefit. If you plan on seeing the doctor more than that, I think you chose the better option.
 
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