UNDERSTANDING YOUR INSURANCE
There are many different insurance companies, but all use the same vocabulary to explain why you might receive a bill from your provider’s office. There can be policy variations within each plan contracted by your insurance carrier. Like you, we also have a contract with your insurance company and are required to collect payments for all charges your insurance carrier may put to your responsibility.
Below is a list of common terms and definitions to help you understand why you might receive a bill from us:
The deductible is an annual amount you pay before any benefits from your health insurance policy can be used. Some services, such as office visits or procedures, may be applied toward your annual deductible until the amount of the deductible has been satisfied. For instance, if your deductible were $2,000, you would pay for the first $2,000 in health care you receive each year, after which the insurance company would start paying its share. Services such as preventive care and immunizations are usually covered at 100% and are not subject to your deductible. However, be aware that some services performed at your child’s preventive visit may not be considered preventive services by your specific insurance plan.
Co-insurance is a percentage of the total cost of care that you are responsible for after your deductible has been met. A co-insurance plan of 80/20 means that your insurance company will pay 80% of allowable charges and you are responsible for the remaining 20%. This applies to all office visits in which your child is seen. However, most insurers do not apply co-insurance to preventive visits.
The co-pay is a fixed amount that you are required to pay at the time of service. This is a contractual agreement that you have with your insurance company. This applies to all office visits in which your child is seen. For most preventive visits, a co-pay is not required. However, if a non-preventive service is performed at a well-child visit, a co-pay may be required by your insurance, as it is considered outside the scope of standard preventive care.
Coordination of Benefits (COB)
This is when a person is covered under more than one health insurance plan. It requires that payment of benefits be coordinated by all health insurance plans to avoid duplicate payments or pay more than the total amount of the claim. If you are asked to contact your insurance an update your COB, it means that the insurance is requiring you to verify whether or not your child has other health insurance coverage, and if they do, to determine which insurance is primary.
Primary insurance is the policy that is billed first. The policy that is billed next is your Secondary insurance. If you have more than two plans, the insurance billed after your primary and secondary plans is your Tertiary insurance. For commercial insurance in the state of Washington, knowing which plan is primary or secondary is determined by the subscriber’s month and day of birth. For instance, if one subscriber’s birthdate is 3/14/1980 and the other is 2/10/1981, the insurance for the subscriber with the 2/10/1981 birthdate would be primary because February comes before March. The year of birth is not a determining factor. There are a couple of exceptions to this rule. If your child is covered under a commercial plan and a Medicaid plan, the Medicaid plan is always secondary. The same is true if your child is covered under a commercial plan and a military plan (Tricare). The military plan will always be secondary. Another exception is if there is a court agreement which specifically states which insurance is primary and secondary. Also note, that while it is common for the secondary to pay the balance that the primary insurance did not, sometimes both the primary insurance and secondary insurance will require their deductible to be met before charges are covered.
If you have other questions concerning your insurance, please contact our billing department at 360-542-1354.