Healthcare Insurance

Did you lie about having health insurance on your tax form?

You don’t have to answer that, but on April 15, 2016, when you file your 2015 taxes, the IRS will know if you had a QHP or Qualified Health Plan or not. Insurance Carriers are now supposed to collect your Social Security number and report it to the IRS has having health insurance.  They have typically collected this information, but now they have to report it to the IRS.  If they don’t, they will be out of compliance.

Here is how it will work.  Next year, when you file your income tax, if your social security number doesn’t pop up as one reported by an Insurance Carriers as having a Qualified Health Plan, you will be receiving an inquiry from the IRS.  You’ll either have to submit proof you did have a QHP or pay the fine.  If you don’t have coverage in 2015, you’ll pay the higher of these two amounts:

  • 2% of your yearly household income. (Only the amount of income above the tax filing threshold, about $10,150 for an individual, is used to calculate the penalty.) The maximum penalty is the national average premium for a bronze plan. Or $325 per person for the year ($162.50 per child under 18). The maximum penalty per family using this method is $975. –
  • Open enrollment is over, but there is one way you can get health insurance without any health questions being asked.  You have until April 30th to take advantage of this “Special Enrollment Period,” so don’t delay. Go to: to run a free quote and find out what it might cost or call me to discuss at 512-301-4442.

© 2017 by VersaClaim, Inc., all rights reserved.

Healthcare Insurance

What Most People Don’t Know About Deductibles

In addition to selling insurance I work with Providers helping them understand all the new regulations and how the Affordable Care Act will affect them. Recently I spoke with a Medical Biller about provider charges, the incredibly high deductibles patients must meet for their insurance plan and what Payer consider to be an allowable service. This particular Biller suggested Providers raise their charges to astronomical levels so patients will reach their deductible faster. This is absolutely wrong and here is why.

The three terms we are discussing here are: Charges, Deductibles and what the insurance companies and Medicare call the Allowable. A Provider can charge whatever they want to Charge for their services. The industry standard is usually 2 or 2 1/2 times whatever Medicare or the Center for Medicare and Medicaid Services (CMS) will pay. You will see the charge, because that is what the Provider puts down on the claim.

We should all know what the Deductible is. That is the amount you typically have to pay before your benefit plan will start paying towards your claims. In the recent healthcare climate, that could be as much as $6,350.

The Allowable is what the insurance company or Medicare deem covered under your benefits and what they will pay for that particular service. Please note that not everything included on your claim from the provider is deemed allowable.

When insurance companies calculate whether or not you have met your deductible, they do it using the allowable amount, NOT the charged amount. Therefore, it really doesn’t matter what the Provider charges, only what the insurance company deems allowable.

If your deductible is $3,000 and the charges are $20,000 but the insurance company only allows $1,000 of it to be paid, then you will still have $2,000 to pay before your deductible is met.

If you are dealing with an in-network provider, you don’t have to worry about “balance-billing.” Balance billing is the practice some providers (who aren’t in network) use to collect the difference between the charged amount and the allowed amount.

I hope this helps clear up some of the confusion. I will post more about how claims are handled and what is expected from you the patient, your insurance company and the provider. Go to to find out more about what can be done with out-of-network claims.

© 2017 by VersaClaim, Inc., all rights reserved.