Health Insurance Deductibles | Max Out of Pocket, Deductibles & Co-Pays



okay let's just get to the point here deductibles copays max out-of-pocket what gives man what's up with that what are we talking about here I don't know are they the same or they're all different this is a question I've had you've explained it to me literally like a dozen different times over the years I'm gonna break it down you know to the ridiculous let's get into it man let's get deep on health insurance think tank comm we like to break it down to the ridiculous so on the doctor office copay benefit okay your copay with some plans will cover the doctor's charge and other services that you have done some copay benefits only cover the doctors charge so that's a big difference if your health plan copay only covers the doctors charge then if on that visit that you go to see him when you have strep throat that strut test is going to be subject to your deductible and if not met that you're gonna get a bill for a hundred and eighty dollars for that strep test reason being is because your copay benefit only paid the doctor's charge which is about on a primary physician about ninety dollars usually and for a specialist about 180 190 so that leaves a lot of people sour because when people go to the doctor and they make their co-payment they feel like they're paid in full on that visit you know as far as they know the copay benefit covers the doctors charge plus the other services that they're having done and that is the way that plans always used to work but as things have gotten more expensive and with these exchange policies now you're gonna see that your copay benefit is only covering the doctors charge it doesn't cover any other services you have done so if you have blood work cultures swab for strep throat an x-ray you know generally the doctors gonna do something rather than just hit your knee and say well your reflexes look good you know so if they do something outside of just check your reflexes those charges are going to fall outside of the your copay benefit or his charge and are gonna fall into additional medical charges that are gonna be you know you're gonna have to pay if your deductible isn't that how about for prescription medications or do most of the providers still do a copay when you go to the the pharmacy you want to pick up your medicine you pay a copay there there's a couple of different ways that that can work let's say that you have a copay then when you go to pick up that medication depending upon the tier that it is your copay will be somewhere between 10 and 40 dollars that's for tier 1 tier 2 tier 3 now there is the potential that the medication that you need is going to be subject to your deductible say if you're taking a Medicaid like it like an injectable medication for MS okay a medication like that a specialty formulary brain medication you know that's going to be safe thousands of dollars a month to take those drugs can be subject to your deductible and max out a pocket okay okay so which brings us to the next question I mean what's up with the deductible and then the max out-of-pocket when it seems like you know once you hit the deductible it should be in the 100 providers right yeah okay so let's delve into membership and all that yeah so used to that's the way it worked a person's deductible was the indicator of how much money they would be out if something bad happened and overtime as medical costs and things have gotten more expensive to make policies cheaper just like the copay benefit only covering the doctors charge what they did was they added coinsurance and that is everybody's had a plan that after the deductible they have to pay you know you know the plan pays ninety ten or 80/20 or 70/30 that's called coinsurance which is basically a second deductible after your primary deductible and those two the deductible and your coinsurance add up to what is your ultimate decider and how much you're gonna pay which is your max out-of-pocket which in today's terms and what I call your ultimate deductible that's what you're gonna have to pay say you have an eighty seven thousand dollar bill over at the hospital you're gonna be responsible for your deductible and your coinsurance which is going to add up to your max out-of-pocket so if you have a thousand dollar deductible and you have a five thousand max out of pocket with an 80/20 coinsurance and you have an eighty six thousand dollar claim the first thousand is on you because that's your deductible the coinsurance the 80/20 is where the insurance company is gonna pay a B and you're gonna pay twenty until that 20% adds up to another four thousand dollars got to and bills to you then the policy will pay a hundred percent because you are at your max out-of-pocket of five thousand dollars on that thousand dollar deductible plan that was great that was really good the script I mean that's as clearly as it's ever been explained to me usually I try to figure that out in my eyes just glass over and it loses me somewhere but that was good sometimes trying to explain it it's you can lose yourself because but what it comes down to is the way I always try and think of it is basically you know your max out-of-pocket is basically in the 21st century is to deductibles the traditional deductible that you pay 100% of and then the 21st century deductible which is the coinsurance which is where you and the insurance company share the responsibility in the bills after the deductible and then that max out-of-pocket States your cap on the most that you can pay with your deductible and your coinsurance yeah well I think that really cleared it up for me I'm sure a lot of other people watching out there so we're gonna put a link to another video where we think that we have a solution for some people there might be a better option than actually I'm waiting for a long time say I hit that deductible and then you know the max out-of-pocket let me ask you something what is the highest deductible that you remember seeing in the highest max out-of-pocket can you do you have any numbers that she remember from any of your clients in the past you know I mean typically a you know a ten thousand dollar deductible with a thirty thousand dollar you know max out-of-pocket would probably be that's probably the the highest out-of-pocket I've ever seen and he typically speaking when you when they develop these plans they're trying to have people somewhere in the neighborhood of vibed to ten thousand and out-of-pocket expenses because most people can absorb five or ten thousand it's when it gets to be thirty or more that you know but but that's about the highest I've seen as far as deductibles and coinsurance is where you know you've got a ten thousand deductible with a thirty thousand max out-of-pocket you know we don't anymore but we used to have a carrier that offered a $25,000 ball then it paid a hundred percent to a million okay now that company doesn't offer that plan anymore but that was a good choice for a lot of people cool cool sounds good well thanks a lot for tuning in guys I appreciate you sticking around at the end we're trying to keep these videos short and sweet and bite-sized chunks for you guys we're gonna link to another video where we think we've found a workaround for those of you who don't want to wait thousands of dollars before your insurance starts kicking in to help you out come check us out at health insurance think tank comm we've got answers to a lot of your questions a lot of resources that can help you out to navigate the healthcare process find doctors frequently asked questions and a whole lot more we'll see you next time

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