Insurance

• This is a statement that will arrive in your mail directly from your insurance company.
• It provides details about your medical insurance claim that has been processed by your insurance company and explains what portion was paid to the healthcare provider and what portion of the payment – if any – is your patient responsibility.
  • Note: every time they provide services, your doctors, dentists, physical therapists and other medical professionals will submit claims to the patient’s insurance company to receive payment.
  • In turn the insurance company sends out EOBs to the patient to inform them of the claims submitted, how much is being covered and how much the patient owes.
• Any portion of the medical expense not covered by the insurance company will then be billed to you by your healthcare provider and payment should be paid directly to the appropriate provider.
• This statement closely resembles a medical bill but it is not a bill.
  • Your healthcare provider also receives a copy of the EOB.
  • Upon receiving their copy, your healthcare provider will process the claim and will send you a bill – if appropriate – for the amount the insurance determined to be your financial responsibility that remains outstanding.

A fixed amount determined by the health insurance carrier payable at time of service.

The amount you – the individual – owes for health care services BEFORE the insurance company begins to pay

For example: If an individual has a deductible of $1,000…

• The insurance company will assign 100% of the financial responsibility for covered services to the patient up to $1,000.
• Once the individual has paid $1,000 for covered services, the insurance company will then begin to pay.

The individual’s “share of the costs” of covered health care services as determined by the health insurance carrier . . . usually calculated as a percentage.

Individual pays the percentage (responsible for their share) AFTER they have completely satisfied their deductible.

For example: The individual has $1000 deductible and a 20% co-insurance…

• The individual is 100% responsible for the first $1000 of their medical expenses for the year.
• Every dollar expense thereafter is then split between the insurance company and the individual with the insurance company paying 80% and the individual paying 20%

So let’s say the insurance company allows $500 for the services rendered…

• If you have not met your deductible, your financial responsibility would be $500
• If you have met your deductible, the insurance company will pay $400 and deem your responsibility to be $100

Indication that your healthcare provider is contracted with the insurance company, generally resulting in less financial burden for the individual.

Chiron providers participate with Medicare, most major commercial insurance companies (including but not limited to Blue Cross, Anthem, Carefirst, Aetna, Cigna, United HealthCare, UMR) and some Medicaid plans and will work with Worker’s Comp and No-Fault (Motor Vehicle Accidents).

Out-Of-Pocket Maximum // Out-of-Pocket Limit // Maximum Out-of-Pocket

This refers to the maximum amount of money you have to pay for covered healthcare services in a plan year

• Costs you pay for covered healthcare services count toward your out-of-pocket maximum including deductibles, co-insurance and co-payments.
• Note: Monthly plan premiums and services not covered by insurance do not count toward your out of pocket maximum.

Once you meet your limit / your maximum out-of-pocket maximum, your healthcare plan will pay 100% of all covered healthcare costs for the remainder of your plan year

Examples of how an out-of-pocket maximum might work:

• Alice has a health plan with a $2,500 deductible, 20% co-insurance and a $4,000 out of pocket maximum plan.
• At the start of the plan year, Alice sees her doctor regularly and receives medical bills totaling $2,500 … this meets her deductible which she pays and counts as monies applied to her out of pocket maximum.
• As the year continues, Alice sees other doctors or specialists or physical therapy and is required to pay her 20% of those medical bills.
  • The 20% represents her co-insurance responsibility and these monies paid also count toward her out of pocket maximum.
• Once Alice has paid $4,000 total expenses — $2,500 associated with her deductible and $1,500 associated with her coinsurance responsibilities – her health insurance carrier will pay 100% of her costs of covered medical care for the remainder of the plan year.
  • Alice will pay ZERO dollars for medical care for the remainder of the plan year