© 2024 Kansas City Public Radio
NPR in Kansas City
Play Live Radio
Next Up:
0:00 0:00
Available On Air Stations

Untangling The Many Deductibles Of Health Insurance

Illustration Works/Corbis

Sure, there's a deductible with your health insurance. But then what's the hospital deductible? Your insurer may have multiple deductibles, and it pays to know which apply when. These questions and answers tackle deductibles, whether an ex-spouse has to pay for an adult child's insurance, and balance billing.

Recently I took my son to see a pediatric gastroenterologist. When I arrived at the office, I saw it was located adjacent to the hospital. My insurance has a large hospitalization deductible so I worried that the visit would not be covered. Nobody in the office could tell me how much an office visit would cost. Why not? Isn't that something I should be able to expect?

Your plan's hospital deductible won't affect how much you pay for the visit to the specialist, whether or not his office is affiliated with the hospital, says Richard Gundling, vice president at the Healthcare Financial Management Association, a professional group.

Here's how it works. Most health plans have medical deductibles that must be satisfied before the plan starts paying for most services. Preventive care is an important exception; there's no deductible for that. Some plans like yours also have separate hospital deductibles. But your hospital deductible would generally only come into play if you were admitted as an inpatient.

"Even if the facility is hospital based, her visit would still be an outpatient procedure and wouldn't affect her hospital deductible," Gundling says.

Though your hospital deductible wouldn't be an issue in this case, if your plan has a regular medical deductible and you haven't yet satisfied it for the year, you may have to pay for the specialist visit anyway.

The doctor's office should have been able to tell you how much the office visit would cost, Gundling says, but you may be better off checking with your insurer to find out how much you'll actually owe out of pocket. Your insurer will have information about both how much it has agreed to pay the provider for an office visit and how much you'll owe based on your health plan deductible and copayment details.

I have insurance coverage through the Affordable Care Act's marketplace. When I visited a cancer clinic for a routine blood check, I asked upfront three times (first over the phone and again when I was there) if all services would be in-network. The answer was yes each time. Afterward I received a bill from an out-of-network lab for $570. Is there anything I could have done to avoid this charge?

In theory, you could have asked the clinic for the name of the lab that it would use for your blood work and checked with your insurer to make sure that it too was in network, says Kevin Lucia, a senior research fellow at Georgetown University's Center on Health Insurance Reforms who co-authored a recent study on state efforts to protect consumers from surprise out-of-network bills.

However, "that seems to be a lot of work for the consumer," Lucia says.

New rules take effect next year for plans sold on the marketplace that will require health plans to maintain up-to-date lists of providers that are easily accessible to consumers.

A CMS official was unable to clarify whether plans must also provide up-to-date listings of labs in addition to other providers.

In the meantime, check with your insurer, Lucia advises. It's not unusual for providers to bill patients for services that are ultimately covered by their plan.

My ex-husband is responsible for health care premiums for our dependent daughter who will turn 21 in October. Under the Affordable Care Act, children can remain on their parents' plans until age 26, but my ex is planning to drop our daughter's coverage when she turns 21. Can he do that?

Yes, he probably can. Although the law requires health plans to offer coverage until adult children turn 26 in most instances, there's nothing that requires parents to provide it. If your divorce agreement required him to pay for your daughter's health insurance until she turns 21, his obligation will likely be satisfied at that point.

If your ex-husband chooses to drop your daughter's coverage and she doesn't sign up for her own plan, however, he may be on the hook for any financial penalty she owes for not having insurance.

Under the health law, most people have to have insurance or face penalties. In 2015, the penalty is the greater of 2 percent of household income or $325 per person.

If he claims her as his dependent, "When he does his taxes he'll have to show that everyone in his household has insurance, and then he'll have to pay the penalty," says Karen Pollitz, a senior fellow at the Kaiser Family Foundation.

Since she's part of his household, the penalty would be based on his income, not hers.

As for your daughter, if she loses coverage she'll be eligible for a special enrollment period to sign up on the exchange, or she may be eligible for Medicaid if she lives in one of the roughly two-thirds of states that have expanded coverage to adults with incomes up to 138 percent of the federal poverty level, currently $16,243.

Copyright 2020 Kaiser Health News. To see more, visit .

Michelle Andrews
KCUR serves the Kansas City region with breaking news and award-winning podcasts.
Your donation helps keep nonprofit journalism free and available for everyone.