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Fee-for-service Plans

Fee-for-service coverage generally assumes that a medical provider (usually a doctor or hospital) will be paid a fee for services rendered. The term refers to the way doctors are paid regardless of who pays. Paying cash-that is, reimbursed out-of-pocket expenses-for medical treatment is a fee-for service arrangement. However, most people don’t pay cash for their medical care. Traditional health insurance-what insurance companies call indemnity coverage-is a fee-for service arrangement.

With fee-for-service insurance, you choose the doctor you want to see, and you can choose a different doctor for any reason any time you feel like it. Mter you've been treated, you or your doctor submits a claim to your insurance company for reimbursement. You will only receive reimbursement for the covered medical expenses that are listed in your plan. For a sample list of covered expenses and/or examples of noncovered expenses.

With some variation, fee-for-service policies reimburse bills for a percentage of a reasonable service charge. (This amount is derived by the prevailing cost of a service in a geographic area.) The portion of the covered medical expenses that you pay, the other 20 percent, is called co-insurance. Sometimes a doctor will charge more than a reasonable amount for a service. If this is the case, you'll end up paying the difference out of your own pocket.

Example: If the reasonable charge for a service is $100, your insurer will probably pay $80 and you would pay $20. But if the doctor charged $105, you would have to pay $25. Many fee-for-service plans pay hospital expenses in full,. so be sure to check with your plan provider.

Most policies have an out-of-pocket maximum-when your covered expenses reach a certain amount in a given calendar year, a reasonable fee for the benefits that are covered on your plan will be paid in full by your insurer and you no longer pay the co-insurance. However, if your doctor bills are more than the reasonable charge, you may still have to pick up some of the tab.

In addition to the out-of-pocket maximum, many/policies place lifetime limits on benefits. When shopping for a plan, it's smart to look for a policy whose lifetime limit is at least $1 million. If the limit is much lower than this, you could run through the coverage if you had major health problems for several years.

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