Deductible: Your starting line
Think of your deductible as the amount you pay out of pocket before your insurance starts sharing the cost.
- If your annual deductible is $1,000, you’ll pay the first $1,000 of covered expenses yourself before your insurance begins paying for services.
- For CRT consumers, this means if your wheelchair costs $5,000 and you haven’t met any of your deductible yet, you will be responsible for the first $1,000. Insurance will pay a percentage of the balance ($4,000), let’s say 80% ($3,200), leaving a balance of 20% ($800). That $800 is your coinsurance, which we will get into next.
- Deductible applies to most healthcare services with some exceptions that vary by insurance plan. Be sure to review your insurance plan details to understand how deductibles are applied
- Deductibles generally reset at the beginning of each year so planning the timing of your healthcare services, when possible, can be financially advantageous to you.
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- Example: having a service provided in December of a year where you’ve met your deductible will cost you less money out of pocket than if you wait to have that same service provided in January when your deductible has been reset.
Coinsurance: Sharing the cost
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Coinsurance is a percentage of the cost you pay after meeting your deductible.
- Once your deductible has been met, if your insurance covers 80% and your coinsurance is 20%, in the case of your $5,000 wheelchair, insurance would pay $4,000 (80%) and you would be responsible for $1,000 (20%).
- Coinsurance also applies to most healthcare services with some exceptions that vary by insurance plan. Be sure to review your insurance plan details to understand how and when coinsurance is applied. It is not unusual to see different percentages of coinsurance for different types of services.
Copay: A Flat Fee for Services
A copay is a fixed amount you pay for certain services like a doctor’s visit or a therapy session.
- For CRT, copays usually don’t apply to your equipment, but you may have a copay for your evaluations or clinic visits. (i.e., $25 for a seating assessment appointment).
- Your insurance plan details will outline services that require a copay.
Out-of-pocket maximum: Your safety net
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Your out-of-pocket maximum (OOPM) is the most you’ll pay in a year for covered healthcare costs. Once you hit this limit, your insurance pays 100% of covered services for the remainder of the year.
How it works with deductibles, coinsurance and copays:
- Deductibles: counts toward your OOPM
- Coinsurance: counts toward your OOPM
- Copays: counts toward your OOPM
- Premiums: do not count toward your OOPM
Example for CRT Consumers:
- Your deductible is $1,000; coinsurance is 20%; and your OOPM is $6,000
- You pay $1,000 (deductible), plus $1,000 (coinsurance on $5,000 wheelchair), plus other costs until you reach $6,000 in total out of pocket expenses.
- After you reach your out-of-pocket maximum, your insurance pays 100% of covered services for the remainder of the year.
Why it Matters:
Senior Market Access Manager
Jim Stephenson is the Senior Market Access Manager for Permobil Americas. Over the past three decades, he has worked on all sides of the healthcare reimbursement spectrum, the last 22 years in the CRT/DME industry. His broad background has provided him with vast experience and a unique perspective in working with payers, providers, physicians/clinicians, and consumers. He is a member of the DME MAC Advisory Councils, the Complex Rehab and Mobility Council (CRMC), multiple industry supporting councils/committees within NCART, and several state associations. At Permobil, he works closely with product development, clinical education, sales, and marketing teams to support CRT providers and consumers.