Help, I don't understand medical insurance
Apr 30th 2013, 8:55 pm
#16
Lost in BE Cyberspace
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Re: Help, I don't understand medical insurance
Hard to say really without looking at the cost, full schedule of benefits and knowing your situation. However, some general terms.
Deductible = the amount you pay before insurance will pay anything
Co-pay = The amount you have to pay per service you receive
Out of pocket max= The max you will pay per benefit year.
Co-insurance = Like a co-pay but for stuff like medical devices
Keep in mind that some plans do not include prescriptions or they are not counted in the deductible or out of pocket max. Also, with a family plan you may need one member to reach the individual out of pocket max or deductible before you can meet the family one. You need to basically evaluate what services you think you will use and the a fudge factor for unforeseen events. That should give you a rough cost and then add the premiums to it. Things like needing a referral vs not needing one and general coverage also plays a part.
Deductible = the amount you pay before insurance will pay anything
Co-pay = The amount you have to pay per service you receive
Out of pocket max= The max you will pay per benefit year.
Co-insurance = Like a co-pay but for stuff like medical devices
Keep in mind that some plans do not include prescriptions or they are not counted in the deductible or out of pocket max. Also, with a family plan you may need one member to reach the individual out of pocket max or deductible before you can meet the family one. You need to basically evaluate what services you think you will use and the a fudge factor for unforeseen events. That should give you a rough cost and then add the premiums to it. Things like needing a referral vs not needing one and general coverage also plays a part.
Apr 30th 2013, 8:58 pm
#17
Joined: Apr 2005
Location: Milwaukie, Oregon
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Re: Help, I don't understand medical insurance
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.
Apr 30th 2013, 9:01 pm
#18
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Re: Help, I don't understand medical insurance
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.
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.
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.
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.
Apr 30th 2013, 9:03 pm
#19
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Re: Help, I don't understand medical insurance
I will never whinge again!
Apr 30th 2013, 9:03 pm
#20
Mouthy Yank
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Re: Help, I don't understand medical insurance
That is good news.
Apr 30th 2013, 9:21 pm
#21
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Re: Help, I don't understand medical insurance
I'm also confused by the whole health insurance thing and we have been here for 10 yrs with great insurance.
We also have an HSA (HSA = tax favored savings account) and I never quite understand why when we pay a co pay and 3 days later get a cheque back from the HSA sometimes for more than the co pay.
It also pays back some of the dental stuff not covered ie. once we reached the max for kids braces on the dental insurance for orthodontics it paid for the rest. With good planning it can work very well, then they reduced the amount you could put in this year
We also have an HSA (HSA = tax favored savings account) and I never quite understand why when we pay a co pay and 3 days later get a cheque back from the HSA sometimes for more than the co pay.
It also pays back some of the dental stuff not covered ie. once we reached the max for kids braces on the dental insurance for orthodontics it paid for the rest. With good planning it can work very well, then they reduced the amount you could put in this year
Apr 30th 2013, 9:24 pm
#22
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Re: Help, I don't understand medical insurance
You also need to take into account the differences between a PPO and HMO in terms of who you are allowed to see. PPO generally more flexible in letting you choose who to see which then comes down to whether they are in network or out of network which may affect out of pocket costs. HMO I think is more restricted.
Apr 30th 2013, 9:35 pm
#23
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Re: Help, I don't understand medical insurance
PPO has an in network and and out network (the latter is subject to massive annual oop max and higher % copays).
As I see it the HMO means your primary care provider has to make referrals for you, you can't refer direct. Much like the NHS (and even our UK private medical insurance).
Am I right?
As I see it the HMO means your primary care provider has to make referrals for you, you can't refer direct. Much like the NHS (and even our UK private medical insurance).
Am I right?
Apr 30th 2013, 9:37 pm
#24
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Re: Help, I don't understand medical insurance
PPO has an in network and and out network (the latter is subject to massive annual oop max and higher % copays).
As I see it the HMO means your primary care provider has to make referrals for you, you can't refer direct. Much like the NHS (and even our UK private medical insurance).
Am I right?
As I see it the HMO means your primary care provider has to make referrals for you, you can't refer direct. Much like the NHS (and even our UK private medical insurance).
Am I right?
Apr 30th 2013, 9:38 pm
#25
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Re: Help, I don't understand medical insurance
re what lansbury said, one the example policy they referred to on the PPO said this...." out of pocket max is the maximum you would pay in any one year for deductable and copayment for network covered services. Once you reach this maximum the plan pays 100% for most services."
Am I reading it right that that is the opposite of Lansbury's experience....say 10% copay up to the MAX of annual max-deductable?
Am I reading it right that that is the opposite of Lansbury's experience....say 10% copay up to the MAX of annual max-deductable?
Apr 30th 2013, 9:39 pm
#26
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Re: Help, I don't understand medical insurance
ps, thank you all x
Apr 30th 2013, 9:50 pm
#27
Lost in BE Cyberspace
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Re: Help, I don't understand medical insurance
The whole system is crazy.
Apr 30th 2013, 9:50 pm
#28
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Re: Help, I don't understand medical insurance
Not sure if this helps any, but on the policy I was sent through it says Calendar Year Out of Pocket Expenses in big print and underneath it says (not including calendar year deductible)- $1k (individual) or $2k (family). So from that I assume it means, once I've paid my monthly premiums and my yearly deductible, the most I'd have to pay each year is $2k (family).
Then again, you know what they say about assumptions...
Then again, you know what they say about assumptions...
Apr 30th 2013, 10:18 pm
#29
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Re: Help, I don't understand medical insurance
Also you have to stay on top of what is covered and what isn't. It can change from day to day (literally! LOL)
For 4 years in a row, I got doctor's-ordered custom orthodics. I paid $20 for the doctor visit (co-pay), and that was it. Everything else, including the cost of the actual orthodics, was covered 100% by my insurance. So I go in to my next yearly appointment, pay the $20 co-pay, get my feet fitted again, and order the custom orthodics. They come in, I wear them, then I get a notice saying I owe the doctor $400 because my insurance denied coverage on the orthodics! After calling and investigating, it seems my insurance dropped coverage of orthodics, even "prescription" ones. Ugh. I said how was I supposed to know that?? My insurance said "you're supposed to check your plan before having anything done". Ugh again.
So my doctor cut me a break on that one and discounted the cost for me, somewhat. After that, I just re-order the same item without getting fitted again, as that's cheaper than getting re-fitted. I have to pay out of pocket for those, now, which comes to around $250 a year.
Rene
For 4 years in a row, I got doctor's-ordered custom orthodics. I paid $20 for the doctor visit (co-pay), and that was it. Everything else, including the cost of the actual orthodics, was covered 100% by my insurance. So I go in to my next yearly appointment, pay the $20 co-pay, get my feet fitted again, and order the custom orthodics. They come in, I wear them, then I get a notice saying I owe the doctor $400 because my insurance denied coverage on the orthodics! After calling and investigating, it seems my insurance dropped coverage of orthodics, even "prescription" ones. Ugh. I said how was I supposed to know that?? My insurance said "you're supposed to check your plan before having anything done". Ugh again.
So my doctor cut me a break on that one and discounted the cost for me, somewhat. After that, I just re-order the same item without getting fitted again, as that's cheaper than getting re-fitted. I have to pay out of pocket for those, now, which comes to around $250 a year.
Rene
Apr 30th 2013, 10:28 pm
#30
Joined: Oct 2006
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Re: Help, I don't understand medical insurance
Sadly why do I feel it might not be the end of the tale 