| First, what is the official definition of
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| | stop paying the 30%??
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| co-insurance?
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| | Stage 3 - The Max Out of Pocket THE
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| Coinsurance
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| | CARRIER PAYS 100%
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| Once you have met your deductible, you
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| | Once you have met your Max out of Pocket
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| pay coinsurance for additional medical
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| | (sometimes called the Copay Maximum), the
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| care. It is a percentage of the billed
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| | carrier will then pay 100% of covered
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| charge. For example, your insurance
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| | benefits, in-network. For our plan
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| company might pay 80%, and then you would
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| | example, let's say we have a $500
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| pay 20%. It is similar to a co-pay, but
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| | deductible, 70/30 co-insurance, and $5000
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| is a percentage instead of a dollar
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| | max out of pocket. If we get a $50,000
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| amount.
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| | bill in a calendar year, you pay the
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| Now, let's dig a little deeper. With
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| | first $500, then 30% until you reached
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| California health insurance, it is common
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| | another $5000 out of pocket. For that
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| to speak of their plan as an 80/20 plan
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| | $50K, you would pay $5500 and the carrier
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| or a 70/30 plan. They are essentially
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| | would pay $45,500. Co-insurance is nice
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| referring to the co-insurance part of it.
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| | but the real reason to have health
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| With the 80/20 example, the health
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| | insurance is the max out of pocket.
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| carrier is picking up 80% of the charges
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| | Co-insurance usually applies to services
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| and you are picking up the remaining 20%.
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| | outside of the office visit and
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| If there is any kind of deductible, you
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| | prescriptions. You will typically see the
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| must pay that first at 100% until met.
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| | same co-insurance percentage for
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| Let's take an example and see how
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| | hospital, lab, surgery, emergency
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| California health insurance plans
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| | (sometimes has separate additional copay)
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| essentially break down into three main
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| | and physician services.
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| stages.
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| | It's important to stay in network for PPO
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| Stage 1 - The deductible YOU PAY 100%
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| | plans. Let's say you have 70/30 plan and
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| Let's say you have a $500 deductible.
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| | you see a doctor out of the PPO network
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| Except for services that are separate
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| | on a non-emergency basis for $1000 of
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| from the deductible (usually office
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| | services and your deductible is already
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| visits and prescriptions...see COPAYS),
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| | met (you're in Stage 2). Two things will
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| you will pay the discounted charges at
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| | probably happen. The health insurance
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| 100% until you meet your deductible. You
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| | plan will probably have a separate
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| can find more information on deductibles.
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| | percentage for out of network...let's say
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| Stage 2 - The co-insurance YOU SHARE A
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| | 50/50 instead of 70/30. Also, the carrier
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| PERCENTAGE
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| | will apply this lesser percentage to what
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| Once the deductible is met, you then
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| | they would pay an in-network provider.
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| start sharing the cost with the carrier.
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| | For example with the $1000 charge,
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| Let's say our plan is 70/30 and the
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| | perhaps the contracted PPO rate is $600
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| charge is $1000. You pay the first $500
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| | (discount is usually 30-60%). The carrier
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| (deductible) and then you pay 30% of the
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| | would then pay 50% of the $600 or $300 of
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| remaining $500...or $150. Of the first
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| | the total $1000. You pay $700. Compare
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| $1000 charge, you would pay $650 out of
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| | this with the 30% of 600 you would pay
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| it. If you have another $1000 charge in
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| | for an in-network provider. $700 versus
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| that same calendar year, you would pay
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| | $180 out of your pocket. Use in-network
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| 30% of the 1000 (or $300) since your
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| | providers!
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| deductible was already met. When do you
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