What are copays, deductibles and coinsurance?

It’s not always clear exactly what your health insurance plan covers when fees and ending costs can feel like they’re hidden behind complex industry terms. So tackling understanding what they mean is important to knowing and using your benefits.

The below terms are all forms of “cost-sharing,” which is when medical services are paid by both the member and the health plan.

Copay — A fixed amount a person pays for qualifying types of services, such as office visits, specialist visits, prescription drugs or other procedures. For example, a member may have a $25 copay for an office visit with a primary care physician and a $40 copay for a specialist. All copays are fixed and detailed in the summary of benefits at the beginning of the plan and can be charged before and/or after a person has reached his or her deductible.

Deductible — The amount you pay for covered services before the insurance company begins to pay. For example, if you have a $2,000 deductible you will pay 100 percent of all eligible expenses until all the bills total $2,000. Once the deductible is paid, you will owe only any copays or remaining coinsurance for covered services. See Also: an article on embedded vs non-embedded deductibles.

Coinsurance — Paid after a person has met his or her deductible, it is a percentage of the allowed amount for services. For example, you have a coinsurance of 20% and the allowed amount for lab work is $100. If you have paid your deductible, you will owe 20% of the allowed amount of $100, or $20. If you have not paid your deductible, you owe the full amount of $100. Not all plans have coinsurance.

It’s important to be sure you understand your benefits when you receive your plan documents. All health insurance plans come with a summary of benefits, which includes informations on all copays, deductible and/or coinsurance. If you have additional questions about your plan, it’s best to contact the health insurance company directly.

You may always find contact information on your member ID card.

ClaimLinx office closed on March 30

The ClaimLinx office is closed on Friday, March 30 to celebrate the holiday with family and friends. We appreciate our clients and partners’ understanding of this time for rest and relaxation for our team.

Please plan any inquiries or need for assistance accordingly. All phone calls and emails will be returned upon our return on Monday, April 2. If you have any issues or questions, please feel free to contact us and a team member will get back as soon as possible.

We’re wishing all of our clients a very happy and rejuvenating weekend!

What is the difference between an embedded and non-embedded deductible?

A deductible is the amount of money that must be paid for covered services before the health insurance company begins paying for expenses. There are two types of deductibles, but the difference matters only for plans covering more than one individual.

The difference has to do with the amount an individual or a “family” must reach before the insurance company begins paying for expenses. Note: in this case a family can apply to a member and spouse, member and children or member, spouse and children.

Embedded Deductible — Each family member has an individual deductible in addition to the overall family deductible. Meaning if an individual in the family reaches his or her deductible before the family deductible is reached, his or her services will be paid by the insurance company.

Non-Embedded Deductible — There is no individual deductible. So the overall family deductible must be reached, either by an individual or by the family, in order for the insurance company to pay for services.

In the past, non-embedded deductibles have been an issue especially for small families, such as a member and spouse because they have fewer people to reach the high deductible.

With the passage of the Affordable Care Act, there were changes to the standards regarding out of pocket maximums that affected how insurance companies structure plan deductibles. All ACA compliant plans must have embedded out of pocket maximums. As a result, most ACA compliant plans now have embedded deductibles.

Also as a part of the law, all family deductibles must be no more than double the individual deductible rate. For example, if the individual deductible is $3,000, the family deductible can be no more than $6,000. Both of these measures were an effort to alleviate the financial stress on smaller families.

However, these rules do not apply to the self-funded Medical Expense Reimbursement Plans ClaimLinx clients use for their benefits, so it is possible our members still have a non-embedded or higher family deductible. Always refer to your summary of benefits for more information regarding your own deductible.

How a claim is processed

See below the steps a claim goes through as it is processed. Claims are processed within 10-15 business days of their receipt at ClaimLinx. Members can view their Explanation of Benefits (EOB) once it has been processed through the member portal.

Once the claim has been processed and coverage has been determined, additional steps are taken before payment is sent to the provider (detailed below). If you have any questions about the process or a specific claim, contact our team at help@claimlinx.com.

How a claim is processed copy

Due date for 1095 forms moved to March

Tax filing deadlines are coming up so some of you may have employees asking questions about their 1095 health coverage information forms. Please be advised at the end of last year the Internal Revenue Service (IRS) extended the deadline for issuing these forms to March 2, 2018.

This means insurance carriers and other insurance providers have until this date to provide Forms 1095-B or 1095-C to members. This 30-day extension is automatic and does not require any paperwork to request it.

However, this does not mean that employees are required to wait to receive this information to file their individual income tax return. The IRS states these forms can be used to assist in preparing a return but are not required to file.

As a reminder, these forms are issued from the primary insurance carrier on your plan, not by ClaimLinx. If employees have not received this form after this deadline, they can request it from the insurance carrier directly.

If you have received any additional instructions from your primary insurance carrier regarding these forms, such as if your carrier is National General, please follow their instructions for filing as soon as possible.