How do health insurance companies decide when to apply costs to one's annual deductible?

It seems they randomly choose when they will pay in full %26amp; when you will pay in full because they decided to ';add it to your deductible';. For example, they'll pay for one x-ray in full this time but next time make you pay for it. (I'm not referring to a car accident that cost $20,000 in surgery %26amp; they make you pay the deductible up front before they pay costs). How do health insurance companies decide when to apply costs to one's annual deductible?
It isn't random at all.





If you have a $500 deductible then the first $500 in charges (not necessarily what the doctor bills but the negotiated amount THEY would pay goes towards your deductible.





There are only three reasons I can think of when that doesn't apply.





First, if the company lists it as a 100% covered service. This is usually but not always because your state mandates that the service must be 100% covered.





Second, if you have a policy that also has co-payments and the service is less than the co-payment.





Third, if you have separate deductibles for services from in-network and out-of-network services. In that case its' possible to have met your in-network deductible but not your out-of-network deductible.





Give your insurance company a call. They can explain how your benefits are applied. And it's always a good idea to keep a benefit summary handy so you can refer back to it if you have questions. Often you can find these summaries with your original paperwork, your benefits administrator and sometimes even on your personal page at the insurer's website.





Best of luck!





How do health insurance companies decide when to apply costs to one's annual deductible?
Insurance companies do not decide on they fly. Rather, they have to make a determination based on the policy explanation of benefits. It can seem confusing sometimes if one does not really understand how their policy works. For instance, many people do not realize that with most plans the copay is something entirely separate from the deductible. Of course, plans and benefits differ from company to company and from state to state so this makes it all the more important to enlist the services of an independent health insurance agent that can help you make sense of it all.
Gatlin,





The health insurance policy you have is a legally enforceable contract that sets out in its provisions what is covered and what is not covered. There is nothing random about it.





Very simply the deductible applies to all covered medical expenses. In return for a lower premium you (or perhaps your employer) chose a deductible that requires you pay those medical expenses before the insurance company participates with you in paying those charges. After you satisfy the copay requirements the company pays 100% of covered expenses.





If you don't understand why a certain charge was not paid look carefully at your explanation of benefits statement or call the company or talk to your agent.
They don't 'decide,' it should be pretty clear. Sometimes if you get lab work done in the doc's office it might be covered by the office copay (assuming you have one), but if you go to a facility it would go towards your deductible.





Regardless different plans work differently. You just need to call and ask how your plan works, because it's not random.
They don't pay ANYTHING until you've submitted enough bills to cover your deductible, UNLESS, your plan covers certain things outside of the deductible.





It's highly possible that your plan is actually changing from year to year, and that's what is creating the confusion.






Mine health ins. company uses the earliest charges against my deductible. Once that is met then it covers the costs. Call your company and ask what formula they use.