What is Deductible:
This is an amount that the patient owes the carrier every year apart from the premium. The patient has to pay this amount before insurance started to pay.
A fixed dollar amount during the benefit period – usually a year – that an insured person pays before the insurer starts to make payments for covered medical services. Plans may have both per individual and family deductibles. ¨ Some plans may have separate deductibles for specific services. For example, a plan may have a hospitalization deductible per admission. ¨ Deductibles may differ if services are received from an approved provider or if received from providers not on the approved list.
** Deductible – Means the amount a subscriber pays for health care services before the health plan begins to pay.
› There is a timeframe for deductibles, usually a year.
› Applies only to services covered in the health plan.
› May not apply to all services.
Update from Medicare 2017 part b Deductible
CMS also announced that the annual deductible for all Medicare Part B beneficiaries will be
$183 in 2017 (compared to $166 in 2016). Premiums and deductibles for Medicare Advantage
and prescription drug plans are already finalized and are unaffected by this announcement.
1. WHAT DOES DEDUCTIBLE MEAN?
Deductible means you are eligible for Medicaid, except for your income. To get Medicaid, you must use your medical costs to get your monthly income at or below the income limits.
2. WHAT IS A DEDUCTIBLE AMOUNT?
It is the amount of your income that is over the income limit.
3. HOW DO I KNOW IF I HAVE A DEDUCTIBLE?
Your Department of Human Services (DHS) Specialist sends you a letter called the Deductible Notice. It gives your deductible amount and tells how you can get Medicaid. You can get Medicaid when your medical costs are more than your deductible amount. Your Specialist also gives you a Deductible Report form to list your medical bills.
4. CAN MY DEDUCTIBLE AMOUNT CHANGE?
Yes. The changes noted below are examples of what can change your deductible amount. You must let your Specialist know within 10 days of any change in:
• health insurance coverage and premiums
• the persons living with you
• your address
• other factors that may affect your eligibility.
5. WHAT KIND OF COSTS CAN I USE TO MEET MY DEDUCTIBLE?
Use costs for medical care such as:
• care from hospitals, doctors, clinics, nurses, dentists, podiatrists and chiropractors
• most medicines
• medical supplies and equipment
• transportation to get medical care.
You cannot use costs that your health insurance or Medicare paid for you.
Make sure you tell your Specialist about all medical bills you and your family owe. Tell him or her even if you have not received the bill yet.
It does not matter how long ago you received the medical services. List your old unpaid bills and each new medical cost you have on your Deductible Report.
6. DO I NEED PROOF OF MY COSTS?
Yes. You must provide proof of your medical costs.
You can use:
• unpaid bills
• paid receipts
• other statements
These statements should show:
• the date of service
• the amount owed or paid
• the person getting the service.
Tell your Specialist if you are having trouble getting this information.
7. DO I HAVE TO PAY MEDICAL BILLS TO USE THEM?
No. But you must have received the medical care before you can use the bill. Paying medical bills is your responsibility. You should contact your provider.
8. WHAT DO I DO WHEN I HAVE ENOUGH BILLS?
Return your Deductible Report and proof of your costs to your Specialist when you have bills or receipts for medical care that total more than your deductible amount.
9. HOW ARE MY BILLS USED TO MEET MY DEDUCTIBLE?
• decides which bills or receipts can be used to establish Medicaid eligibility
• can use paid bills to establish eligibility only for the month you received the service
• can use unpaid bills to establish eligibility for any month
• will use the oldest unpaid bills first
• can use any paid or unpaid bill only once to establish eligibility.
10. WHAT HAPPENS NEXT?
Your Specialist will send you a written notice about your Medicaid coverage if:
• your allowable costs are more than your deductible amount
• you still meet the other eligibility requirements.
Your Specialist will tell you if your allowable costs are less than your deductible amount.
Deductible Guideline from BCBS
An amount you could owe during a coverage period (usually one year) for covered health care services before your plan begins to pay. An overall deductible applies to all or almost all covered items and services. A plan with an overall deductible may also have separate deductibles that apply to specific services or groups of services. A plan may also have only separate deductibles. (For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible.)
What is the overall deductible? Example
For network providers $1,300 individual / $2,600 family; for outof-network providers $1,300 individual / $2,600 family.
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
In insurance policy terms, a deductible is the amount of money which the insured party must pay before the insurance company’s own coverage plan begins. In practical terms, insurance companies include a deductible in their policies to avoid paying out benefits on relatively small claims. A typical auto insurance policy, for example, may carry a $500 deductible. If the owner of that car accidentally hits another car while parking and both drivers agree the damage is minimal, he or she would pay the $500 repair bill out of his or her own pocket. Insurance companies would not encourage a claim for such minor damages.
However, this payment of $500 means that the next accident claim would be covered by the insurance company. The car owner is said to have ‘met the deductible’ and is now eligible for complete protection. The same holds true for medical insurance. Patients who visit the emergency room for a minor injury or procedure would have to pay out of pocket until they have reached the level of the deductible. If their medical expenses on a visit to the hospital would exceed the deductible, then the insurance company would pay the total charges minus the deductible. In either scenario, the policy holder is almost always held responsible for a small portion of their claims.
The amount of a deductible is almost always proportional to the amount of the premiums (regular payments) charged by the insurers. In order to have a lower deductible, even as low as $0, the policy holder would have to agree to higher premiums. For those who want lower premium payments, they must agree to a higher deductible. There are pluses and minuses to either option- one expensive accident or medical procedure could bring on a very high deductible payment, or a lifetime of good health and few automotive claims could make higher premiums a relative waste of money. Then again, having total coverage with little to no deductible can be a very comforting thought during a crisis, or not paying too much for unneeded coverage can help keep household finances manageable.
A deductible of some kind should be expected with any medical or automotive insurance policy. When shopping for affordable coverage, be sure to ask specific questions about the deductible and other obligations left to the policy holder. An exceptionally low premium rate may signal an equally exceptional high deductible amount. Try to find a balance between affordable premiums and a fair deductible when buying insurance.
Are there services covered before you meet your deductible?
Yes. Preventive services are not subject to the deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible.
Beneficiaries who use covered Part A services may be subject to deductible and coinsurance requirements. A beneficiary is responsible for an inpatient hospital deductible amount, which is deducted from the amount payable by the Medicare program to the hospital, for inpatient hospital services furnished in a spell of illness. When a beneficiary receives such services for more than 60 days during a spell of illness, he or she is responsible for a coinsurance amount equal to one-fourth of the inpatient hospital deductible per-day for the 61st-90th day spent in the hospital. An individual has 60 lifetime reserve days of coverage, which they may elect to use after the 90th day in a spell of illness. The coinsurance amount for these days is equal to one-half of the inpatient hospital deductible. A beneficiary is responsible for a coinsurance amount equal to one-eighth of the inpatient hospital deductible per day for the 21st through the 100th day of Skilled Nursing Facility (SNF) services furnished during a spell of illness.
Most individuals age 65 and older, and many disabled individuals under age 65, are insured for Health Insurance (HI) benefits without a premium payment. The Social Security Act provides that certain aged and disabled persons who are not insured may voluntarily enroll, but are subject to the payment of a monthly premium. Since 1994, voluntary enrollees may qualify for a reduced premium if they have 30-39 quarters of covered employment. When voluntary enrollment takes place more than 12 months after a person’s initial enrollment period, a 10 percent penalty is assessed for 2 years for every year they could have enrolled and failed to enroll in Part A.
Under Part B of the Supplementary Medical Insurance (SMI) program, all enrollees are subject to a monthly premium. Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute. When Part B enrollment takes place more than 12 months after a person’s initial enrollment period, there is a permanent 10 percent increase in the premium for each year the beneficiary could have enrolled and failed to enroll. The 2016 rates are as follows:
The benefits of the Plan will be available after satisfaction of the applicable Deductibles as shown on your Schedule of Coverage. The Deductibles will be increased in the future in direct proportion to the increase as determined from the cost-of-living adjustments based on the Consumer Price Index (CPI-U).
The Deductibles are explained as follows:
1. The individual Deductible amount shown under “Deductibles” on your Schedule of Coverage must be satisfied by each Participant under your coverage each Calendar Year. This Deductible, unless otherwise indicated, will be applied to all categories of Eligible Expenses, before benefits are available under the Plan.
2. If you have several covered Dependents, all charges used to apply toward an “individual” Deductible amount will be applied toward the “family” Deductible amount shown on your Schedule of Coverage. When that family Deductible amount is reached, no further individual Deductibles will have to be satisfied for the remainder of that Calendar Year. No Participant will contribute more than the individual Deductible amount to the “family” Deductible amount.
The following is an exception to the Deductibles described above:
Eligible Expenses applied toward satisfying the “individual” and “family” Out-of-Network Deductible will apply toward both the Out-of-Network and the In-Network Deductible. However, Eligible Expenses applied toward satisfying the “individual” and “family” In-Network Deductible will not apply toward satisfying the Out-of-Network Deductible.
• 2016 PART A – HOSPITAL INSURANCE (HI)
• $315.00 a day for 61st-90th day
• $630.00 a day for 91st-150th day (lifetime reserve days)
• $157.50 a day for 21st-100th day (Skilled Nursing Facility coinsurance)
• Base Premium (BP): $407.00 a month
• BP with 10% surcharge: $447.70 a month