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Discounted Rate Procedures/Benefits.

J.R.

Guru
1000 Post Club
1,971
Texas
Would anybody be able to clarify the following for me?

Client A has a mid-level deductible (say $2000) plan, 80/20 co-insurance, $20 co-pay for physician visits and a $5000 deductible for maternity w/ covered expenses @ 100%.

When the insurance carrier receives a bill for client A visiting the doctor the bill will be repriced to reflect the discounted rate if it is a covered expense. Is it possible for client A to receive the discounted rate that the insurance company would get if Client A did not have the $20 co-pay (paid all of the money upfront herself) feature or if the procedure was not a covered expense (i.e., Client A gets pregnant and did not have the aforementioned maternity benefits)? Thanks.
 
If the doc visit is a covered expense the repriced rate would prevail assuming the client uses a par provider. In addition, the amount paid for the doc visit would accrue towards satisfying the deductible . . . something that does not occur when one has a copay.

If the policy does not have maternity benefits there is no repricing.
 
And maternity is a good topic since not only isn't there re-pricing but also no stop-loss if they happen to get pregnant without coverage.

Not everything is a normal pregnancy. My wife had many complecations during her pregnancy and a nightmare birth with complications after the birth. I can't even imagine what they bill would have been.

A lot of agents don't like discussing maternity. Bad move. Most clients think it's included - especially clients who are used to group coverage. Other clients may assume it can be added. In Maryland maternity can never be added after the policy is issued.
 
Interesting, in California the carriers offer a switch-over to a maternity included plan if the subscriber becomes pregnant and has a no maternity plan. Most go over to a $5000 deductible PPO plan from whatever plan they had and there is no underwriting for this change.

Dave
 
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