I recently moved to the United States, and I’m confused about how payments work here. I have a high-deductible plan that started just three weeks ago, and I’m supposed to pay fully out of pocket until I reach $3,200 for the whole family. However, yesterday, I had an appointment with a primary care nurse practitioner to get a prescription for a medication I used back home and for a recently diagnosed psychiatric condition. I got what I needed and left, but no one asked me to pay anything!
How do payments work here? Back home, I always paid upfront before getting any service. Isn’t that the case in the U.S.? When and how am I supposed to pay my share?
You’ll get an Explanation of Benefits (EOB) letter from your insurance provider. It’s not a bill, just a breakdown of what you might owe the medical facility. It usually shows how much of your deductible you’ve paid so far.
You’ll also get a bill from the medical facility. The amount you owe should match on both the EOB and the bill. If it doesn’t, you’ll need to follow up to find out why.
You’ll have copays or cost shares for your appointments, which might vary depending on the type of doctor or the reason for your visit (clinic vs. hospital). You don’t always have to pay the full deductible first. Sometimes, it’s just your copay or a portion of the visit cost until you reach your deductible, depending on the type of doctor or visit.
After your appointment, you’ll get an Explanation of Benefits (EOB) from your insurance and a bill from the doctor. Try to get your EOB before paying the doctor because it shows what you actually owe. Doctors have negotiated rates with each insurance plan, so what you pay with insurance is different from the cash rate without insurance. The EOB will show what was charged, the allowed (negotiated) rate, what the insurance paid, and your balance. It will also update you on your deductible and out-of-pocket max.
Once you’ve met your deductible, you work toward the catastrophic cap, say $5K. If you’ve paid $5K out of pocket during the year, the insurance covers the rest for all covered services. So, if you end up in the hospital, they’ll pay the entire bill.
I guess I’ll pay the full amount until I meet the deductible.
I read on the insurance website that they cover preventive care services even before the deductible is met. What if I get both preventive and non-preventive services during a visit? Will they charge me partially for the visit?
Each plan is different. I pay the full negotiated rate for specialists like neurology, but only part for routine visits and my Crohn’s treatments until I meet the deductible. It depends on how your insurance is set up.
That’s right. If you go in for an annual exam and also have a rash that needs a prescription, you’ll be charged, and it won’t be a “free” visit anymore.
Many doctors’ offices will just send a bill. The front office staff doesn’t handle payments anymore because they have a centralized billing office. So, you’ll get a bill after you receive care.
You’ll actually get two things: an Explanation of Benefits (EOB) from your insurance company and the actual bill. The EOB is not your bill. It explains what the insurance will pay to the doctor and what you are expected to pay.
Some people panic when they get their EOB, not understanding what it is. When they get the actual bill, they see it’s not the amount listed in the EOB.
So, wait for the actual bill and then deal with it.