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OUT OF POCKET [OOP] EXPENSES
Classic: The portion of medical expenses a patient is responsible for paying.
Modern: Refers to the maximum you will pay during your policy period, which is typically a year, before your plan starts to pay 100% of your allowed amount. The costs of your deductible, co-pay, and co-insurance are included here, but not your premium.
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OUT OF NETWORK [OON] EXPENSES
Classic: “Out-of-network” health care providers do not have an agreement with your insurance company to provide care. While insurance companies may have some out-of-network benefits, medical care from an out-of-network provider will usually cost more out-of-pocket than an in-network provider.
Modern: The amount that a health care insurance plan will contribute toward out-of-network services will vary by your insurance company and is often based on a “reasonable and customary” amount that the service should cost
Example: If you go to an out-of-network dentist and are billed $300 for the service, your insurance company may contribute $200 toward paying this cost because $200 is the amount it has decided is “reasonable and customary” for this service. When out-of-network, any remaining cost above this amount ($100 in this case) may have to be fully covered by the person receiving care. When out-of-network, the usual coinsurance rates that apply in-network may not apply out-of-network. Additionally, out-of-network service costs may not count toward an annual deductible.
CHARGE-MASTER: https://medicalexecutivepost.com/2024/11/20/charge-master-medical-bills-paradox/
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Filed under: Ask a Doctor, CMP Program, Glossary Terms, Health Economics, Health Insurance, Healthcare Finance | Tagged: annual deductible, charge-master, CMP, co-insurance, co-payments, deductibles, FEES, Health Insurance, INSURANCE COMPANIES, medical costs, medical expenses, OON, OOP, out of network, out of pocket, premiums | Leave a comment »
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