Zez

Help, trying to understand US medical insurance in order to understand what the package they are offering is. I don't understand it at all!

Options are:

PPO with a $150 deductable, 10% copay on some stuff (some big stuff, including inpatient hospitalisation). Annual out of pocket max $2000 member, $4000 family if in network, obviously more if out.

HMO - generally lower annual out of pocket max, Copays are fixed rather than a %

Kaiser- higher annual out of pocket max. Fixed copays.

We don't get it!

On the PPO, the annual out of pocket max, does that mean the max of all the copays ie if you got hit with a $500000 bill for a hideous accident for eg, you would pay $2000, not 10% of the bill?

Can anyone shed any light. If it helps, we are risk averse!!

Zez

Sorry, how rude, meant to say thanks in advance!

DavidLemon

Been in the US 2 years and i have not got the foggiest how medical insurance works. I have HMO with deductible, Deductible IND $1000 FAM $2000, $20 copay. Everytime my kids see a doctor i get lumbered with a huge bill.

Last was my little girl was advised by the doctor to have an ultrasound on her kidneys because she had a UTi, and that stung me close to $800 after all the bills finally stopped dripping through the mail.

Zez

Oh my goodness $800....is that because its still within the $1000 individual deductable?

Sounds hideous....come back NHS, all is forgiven!

Poppy girl

Been here since 03 and still not got a clue, once you start to crasp a bit of it they change things.

Jerseygirl

I've been here since June '96...still not got a clue. All I know is we have excellent healthcare insurance...it also covers meds...but we have still paid out several thousand this year already. That's not including the monthly premiums.

Pulaski

Gee, three replies already and no explanations, ...... and I thought I didn't understand it!

Every time you visit a medical practitioner you have to put your hand in your pocket for the copay. It is typically $10-$30 for GP visits, but can be higher for specialists or "out of network" visits.

After you have paid your copay and left, the practitioner's admin dept sends the bill to your insurers, who look at your coverage and claims for the year compared to your deductible. Which is how much you have to pay before the insurance pays anything. So if a GP bills you $250 for a visit, with a $25 copay and you have a $200 deductible. You will pay $25 at the point of service, the insurer will pay $25 (being the $225 balance less the $200 deductible), and the GP's admin dept will send you a further bill for $200 several weeks later for the balance not paid by the insurers.

Percentage copays suck and should be avoided! I had a 10% copay on hospital care and got a bill for over $2,000 for a three night visit and minor skin surgery!

The maximum out of pocket should be a good guide to the "worst case scenario", but I'm not certain if that includes copays.
S
The in network v out of network relates to practitioners pre-approved by your insurer, and essentially means the practitioner has accepted the insurers billing terms (insurers pay a discounted rate), and which insurer is best can be critically dependent on the number of in network providers. A few years ago my employer's dental coverage didn't have an in network dentist among the 10 or more dentists where I lived, and only two within 30 miles! My wife needed minor oral surgery and despite there being numerous surgeons with the right specialization, there were only two in network within 60 miles!

Depending on the terms of your insurance, copays, deductibles, and maximum oops can all be higher if you use out of network services.

Zez

oh goodness, We're doomed!!

Help, does anyone understand? Most importantly, is the annual max deductable really all you can get stung for (i.e including any % copays)?

Poppy girl

Good question thats what I always wonder!

Zez

I think can live with a $x copay. A 10% copay if it isn't capped at an annual max (which i hope from my understanding it is) ....not so much!

GeoffM

Probably you know about as much as the average call centre for one of the insurance companies. Nobody understands it fully!

I can give you my experiences, but even then I was on a different plan to my wife and kids so the costs varied - but tomorrow all will be harmonised . I was paying $10 per prescription item. That doesn't count towards your OOP max. Every doctor visit was $30 or $40 (can't remember which), same for a specialist. Preventative care was free, like vaccinations and even a vasectomy, but cheekily they still charge for the visit itself - ie the $30/40. Free eye checkups, but again they charge for the visit.

As I understand it, it would be the $2k, not the 10% total.

A fair chunk of your premium seems to go on the endless paperwork arriving through the mail and after each visit and prescription. I probably have more paperwork for the healthcare than I do for all my bank/credit card statements combined.

Our son went to the dentist which was at least partly covered under Kaiser. Bill of over $1k for a couple of extractions and fillings. Then arguments as the dentist is part of a bigger organization, and they charge differently to the dentist, and then involve Kaiser... three different figures for what we actually owe.

Then our daughter went to ER, can't remember why now. But our nearest Kaiser was 45 minutes away, whereas the nearest ER was 15. Wife opted to go to the local one against my wishes, now saddled with a bill of over a grand just for a 5 minute check-up by a nurse saying there was nothing significantly wrong.

It's all a lottery anyway.

Speedwell

It works like this. Your coverage will say it pays 90 percent, with a 2000 dollar deductible, for example. So out of a bill of several thousand or so dollars, you pay the 2000 deductible (if you have not yet satisfied it all or in part), plus 10 percent of the remainder. That means the insurance pays their 90 percent of their negotiated fees (the negotiated fees do save you a lot of money) and you pay 2000 plus 10 percent of the rest.

So say that the insurance says "the bill would have been 50,000 dollars, but the provider and we have an agreement that they will only charge us X for this procedure and Y for that test, etc." They manage to get the bill down to, say 30,000 dollars. Out of that they take your deductible, so 28,000, and then they pay 90 percent of that, so they wind up paying 25,200 dollars. You pay 2000 plus 2800, so your cost becomes 4800 dollars.

Now a hypothetical bill of 5 million dollars, for a grotesque accident with long-term care and therapy and restorative surgery, or for an aggressive cancer treatment, or for a baby with congenital problems... the math is similar, but. Policies frequently have a lifetime maximum payout of 1 million. So if the insurance company successfully negotiates the charges down to, say, 3 million, you are on the hook for a grand total of 1,988,020 dollars.

Out-of-pocket maxima go a long way toward reducing these amounts, but you are still responsible for what is over the lifetime coverage amount.

Now reflect that I was once refused lifesaving surgery until I could come up with the full amount of the deductible and the co-pay in cash before the surgery date.

Save your pennies, folks. Cheers.

Poppy girl

I have found you can barter with them when a bill comes in and also if you pay cash.

lansbury

That is the maximum out of your pocket you pay in a year. I tested this one year by having surgery, which with MRIs etc before hand, ran up a bill of just over $40,000. My max out of pocket was at that time $4,000 and that was all I paid. Trying to remember if I still had to pay my $25 co-pay for office visits after that, but I don't recall having to.

Look for something in the policy that says what is covered once you reach your maximum out of pocket expenses. Mime said 100% coverage after that point.

Zez

Oh my goodness! So the % deductable is on top of the annual max oop then? So avoid any policy with % copays, rather than fixed $100 here or there. In our case, avoid PPO (we have a choice). Is that right?