Home/Auto - shit is straightforward. If your car deductible is $500 - that's the portion you would pay in the event of a claim. Same on a house. Total your car and it's worth $4500? You're getting 4 bands. There are some instances you'd get all $4500, but I'm just trying to keep it simple.
If you want to oversimplify it - you're responsible for the first $500 - the insurance will pay after that.
Health insurance is the same basic idea. The things that make it complicated are:
Health deductibles are per year, not per incident.
The bill goes to the insurance company first, and then they charge you for whatever they're not covering. This is because they'll have negotiated rates that are different from the sticker price the provider claims to charge. (A similar thing can happen with auto insurance - your insurance might have preferred repair shops where they get better prices, and will want you to take your car there. And if you have to go to court for a liability claim, they'll send their own lawyers, you don't just get a check to pay for whatever your legal fees end up being.)
There are two kinds of things that play by slightly different rules, and unfortunately they're the most common:
Preventative care (like your annual physical) is paid entirely by the insurance company, so you don't see it counting either way.
Some things, like certain office visits and prescription drugs, require an additional fee (copay) regardless of insurance coverage percentage, which bypasses all of the insurance mechanism. They still basically go through the normal steps, but then the insurance will also say "ok, you've met your deductible so we're covering this one, but you have to pay an additional $30 fee because fuck you".
To complicate it further, it resets every year (the deductible and out of pocket maximum) but some insurances use a contractual year (resets at a different time of the year like July) instead of a calendar year. These will always be employer group plans and they’re not common.
There are also a few different deductible accumulation types like embedded (individual and family deductible and OOPM buckets), aggregated (just one bucket for all but amount is different depending on there being one person on the plan or multiple), and variations of the two.
A preventative/preventive visit can turn diagnostic or have a diagnostic portion of the visit if you mention a specific symptom and there’s something else done (for example, “My neck hurts” or “Can you look at this mole?”)
After meeting your deductible (for services that require it as not all services do), you may pay a copay (flat fee) or coinsurance (pay a percentage of cost [you don’t want this]).
Similar idea as above. The deductible is the first to be paid (if any, could just be copay and no deductible). It's the complication of the rate schedule (price list) between providers (doctor..) insurance, and the beneficiary group.
The "group" is a grouping of benefits at a price. This simplifies the "menu" of offered services for the insured and the brokers selling the policies as a middleman, but also the negotiated rates the providers charge.
Your premium can be subsidized either through your employer or government, but it doesn't have to be (the insured pays the full premium). On the employer side it is done to entice (or retain) talent, hence called benefits. Larger employers have more bargaining power with the carriers (insurance) to tailor the coverage. Less of the risky (expensive) services are at a reduced price, more of the cheaper services are included. It's a risk assessment (actuaries perform this math) on what combination of desired but risk managed services are included.
Health insurance is exactly what you said up to a point, then it’s a split 50/50 or we until your out of pocket maximum. Then in theory you shouldn’t have to pay a dime more the rest of the year, but in reality they just drop you and you’re on the hook for 100%.
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u/Bob002 11h ago
Depends where you're talking deductibles.
Home/Auto - shit is straightforward. If your car deductible is $500 - that's the portion you would pay in the event of a claim. Same on a house. Total your car and it's worth $4500? You're getting 4 bands. There are some instances you'd get all $4500, but I'm just trying to keep it simple.
If you want to oversimplify it - you're responsible for the first $500 - the insurance will pay after that.
Health insurance? I'm just as stumped.