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EOB (Explanation of Benefits), Deductibles, Coinsurance and Copays - EXPLAINED - YouTube
Channel: Hindsight 101
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hello and welcome to hindsight 101 where
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you'll learn about things that will
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help you in everyday life now if your
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medical or dental explanation of
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benefits or EOB for short has you
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confused I'm here to help you out now
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we're going to talk about deductibles
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coinsurance and co-payments so stay
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tuned hello I'm Derek and first we're
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going to get some basics out of the way
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like a few definitions of evo co-payment
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coinsurance and deductibles then we're
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going to talk about how an EVO is
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different from a regular bill and then
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also your rights if your evo is
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different than your bill so if you don't
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want to watch all of this then skip
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ahead i'll put the timestamp below we're
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actually going to get to an example of
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what a TBL looks like okay first an EVO
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or explanation of benefits is not a bill
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it's basically a detailed summary of all
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the procedures that you have done this
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is not to say your evo won't reflect
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what your bill is but it's probably best
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way to describe it a pre bill so you
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know what to expect when your bill does
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come if your bill is not the same as
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your evo then you need to look into that
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and then you have a few rights if there
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are issues first and foremost you can
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request an itemized bill from your
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healthcare provider and that way you can
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check code by code to see if everything
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matches up and there was no mistake also
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you want to check your information to
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make sure that wasn't a misspelled name
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or social security number anything else
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that identifies you because mistakes
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always happen and that's how you can get
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billed incorrectly next once you get
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your itemized bill you also want to
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check for duplicate charges because your
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insurance company will deny those
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charges but the healthcare provider may
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still charge them not knowing they
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doubled up on your charges you could
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always call the billing department of
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your health care provider and have them
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go through each item step by step and
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explain to you I've had this done
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because I don't know what cpt 89 code
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means and what that procedure actually
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was as opposed to when I was there and
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they were giving me the procedure I
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don't know the technical names for them
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so I want to know and i'll have them sit
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down with me what it takes
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hour and a half an hour and it's your
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right for them to do that and lastly if
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all else fails there's always an appeal
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process now it's different for each
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health care provider but yes you can
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appeal any charges that you have if you
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feel something was in the wrong oh and
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side note and if you don't get an
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explanation of benefits at all but you
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get a bill never pay the bill until you
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get that explanation of benefits you
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always want to make sure they match up
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and there's no confusion because maybe
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the hospital just sent you a bill before
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the insurance paid for it so then you
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have to go through the process of
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getting a refund or different things
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like that so always wait for your evo
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before you pay your bill if the bill
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comes first so first let's talk about
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the definition of a deductible a
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deductible is what you have to pay
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before your insurance kicks in just like
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car insurance where you may have a
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five-thousand-dollar deductible and then
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with the health care what you have to do
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is say your bill was a thousand but your
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deductible is 200 so before they'll kick
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in and pay any part of that thousand you
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have to pay at least 200 of it so and
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then once you pay 200 you have 800 left
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and the insurance company will pay the
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800 800 plus 200 is a thousand know that
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depending on the healthcare provider
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every deductible is different plus
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whatever plan you choose so make sure
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you look into that before you have the
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procedure so you know what your payments
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are going to look like going into it so
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next let's talk about co-insurance soco
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insurance is a part of the bill you have
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to pay after you meet your deductible
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maximum and basically what that means is
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depending on your plan the insurance
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provider will pay eighty percent and you
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have to pay 20 and there's usually a
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maximum for that too and once you hit
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that maximum then all procedures are
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paid for I'll show you more once we get
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to an example and lastly a co-payment a
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co-payment is basically a payment that
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you have to pay to the actual doctor or
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hospital during the time of your visit
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or procedure not all plans will have a
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copay so make sure you look into your
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plan to know ahead of time if you if you
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need to pay once you get to the doctor's
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office now that we got all that out of
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the way let's go check on an example I'm
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going to cover two examples the first
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one will be where the insurance company
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covered everything that's because I had
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a physical and a physical
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is covered under preventive care and
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when you have preventive care they
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usually cover that a hundred percent and
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then I'll show you another one where the
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insurance company didn't cover all the
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expenses of the procedure so as you can
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see here the ax total amount billed was
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324 dollars and then you have the little
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minus whatever is in this box will be
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subtracted from the 324 so there is an
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insurance discount and basically what
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that means is the insurance company and
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the hospital worked out an agreement
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that a procedure or procedures will cost
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a certain amount so they'll take off a
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discount so whatever 324 minus two
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hundred and twenty one thousand twelve
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cents which equals 102 dollars and
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eighty eight cents that's how much I
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would have owed but since the insurance
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company paid for that my responsibility
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is zero and nothing was applied to my
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deductible as you can see down here
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which is kind of a normal view for an
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EOB the amount billed the insurance
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discounts what the insurance company
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paid and then what my responsibilities
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should be so basically when I get a bill
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in the mail from the hospital it should
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also be zero dollars so let's go to the
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next example now in this example similar
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to what we saw before the total amount
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billed is 865 dollars minus whatever the
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discount is and whatever the insurance
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paid the insurance discount was 688
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dollars six hundred and eighty eight
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dollars minus 865 dollars left a balance
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of 177 this procedure wasn't covered yet
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by insurance so they didn't pay anything
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so in the end I owe 177 dollars and 177
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dollars was also applied to my
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deductible so what that means is I owe
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177 dollars so when I get a bill from
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the hospital it should be a hundred and
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seventy seven dollars and then as before
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you can see kind of the normal weight
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would look if you got this in the mail
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you'd see the procedure you'd see what
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charges were applied what the insurance
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discount was if your insurance company
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paid anything and then what your
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responsibilities should be so my bill
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should match that this is kind of a
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breakdown of procedures and how much
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they cost so if you did have a
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discrepancy you would ask the hospital
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for an itemized bill and you want to
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match up the procedures and the
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procedure codes to make
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there wasn't any double billing or
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something was Miss coated or anything
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like that you also want to check your
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name address account number Social
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Security whatever that whatever
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information that identifies you you want
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to make sure it all matches because any
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of that could cause an error in your
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bill next we'll talk about deductibles
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and coinsurance you can see an example
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here bob has to pay a maximum of a
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thousand dollars for in-network and a
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max of three thousand dollars for
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out-of-network services so basically
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what that means is before the insurance
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company pays anything bob has to at
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least pay a thousand dollars in network
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or three thousand dollars for
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out-of-network services and the
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difference between in-network and
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out-of-network is your insurance company
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has doctors and hospitals that they've
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contracted with that'll charge a certain
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amount and that's in-network services
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but if you go outside of that because
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you have a special doctor and they
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charge whatever they want you can still
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go to them but your deductible is higher
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so your out-of-pocket basically is
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higher bob has been to the doctor and he
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had some procedures done and he had to
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pay two hundred dollars for his
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in-network services he's paid 200 so
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subtract 200 from a thousand so he still
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has to pay eight hundred dollars within
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the calendar year before the insurance
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will pay anything this is also applied
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to his out-of-network services so but
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since it's $3,000 subtracted from 200 he
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still has to pay two thousand and eight
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hundred dollars before insurance will
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kick in once this is covered then we're
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going to move over to co insurance so
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now we're at co-insurance and as you can
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see above within this calendar year bob
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has met his deductible for in-network
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and out-of-network services so now we
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need to go to co insurance and basically
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what co-insurance is once your
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deductible is met co insurance kicks in
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and co-insurance varies by plan same as
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the deductible amounts vary by plan the
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insurance company will pay eighty
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percent and you have to pay twenty be it
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all depends on what the procedure is and
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your plan so in this particular one the
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co insurance is fifteen hundred dollars
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in network and twenty five hundred
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dollars out of network what happens is
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when bob has any procedure the hospital
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will pay eighty percent of it and he has
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to pay twenty percent and
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he reaches a max of fifteen hundred
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dollars then everything's covered a
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hundred percent in network or for
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out-of-network services again bob has to
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pay twenty percent the insurance company
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will pay eighty percent of whatever
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procedure he's having once he meets 25
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hundred dollars every autumn network
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service will be covered with in that
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calendar year so let's look at this
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example bob has $1,500 Mac he's already
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paid in five hundred dollars remember
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after deductible and then the remaining
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he still has a thousand before
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everything's covered a hundred percent
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and then same as out of network bob has
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a max of 2,500 he's paid 500 they apply
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to both so he still has to pay 202,000
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sorry out of network before all autumn
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network services are covered with in
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that calendar year so I hope you've
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enjoyed this if you have any questions
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leave them below thank you take care
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