civilservant

That's a great real world example, and am I glad your wife had a positive outcome.

hutchison

thanks, must say the time between injury & billing is nerve racking, i was confident with the policy but always err' on the side of caution. If i was a contractor, I would be asking the insurance company to give me the 'in network ' addresses & names for emergency medical services by state, and you can usually do that by punching in the zipcode for in network providers on your insurance site. Locally, we are mostly covered by in network.

just for refs tooth extraction is surgical wisdom probably 1.5-2.5k after ins, just guessing.

John123456

hutchison
Thank you for your very detailed real life example, and I hope your wife is doing much better now.
I hope there were more people coming with such examples, so we all could learn about how things work over there.
I bet the experiece of your wife being paralyzed from her waste down was a scary time for both of you.

Let me ask you a few questions if you don't mind:

1. So, if I understood correctly the bill from in network hospital was $295K, and the hospital was IN network

From what I am reading , most of ambulance journies are on OUT of network basis, so good thing yours was IN network.
The care provided to your wife, after she became discharged from the hospital, was also on IN network basis, which was easier for you to arrange as you had time to shop around to make sure you are chosing those that are IN network.
You didn't have much time to decide which hospital to take your wife to when she got paralyzed that morning, so I suspect you were prepared in advance for such eventuality and you knew if something serious happened, which hospital to head to.
This is the first time that I am learning about such thing as OUT of network expenses being covered by your insurance policy, which makes me a little confused. If these OUT of network services/care is being covered by your insurance policy, shouldn't it be called IN network service?
Is it a common thing that OUT of network services are covered by people's health insurance?
I've always though that OUT of newtwork costs were your own, and you were responsible to cover them in full by yourself and that no insurance company would be willing to cover them, unless it was an emergency, as discussed in that video I posted earlier, but even in that case the insurance company refused to pay for that emergency.

2. "our particular company policy is you pay 20% they pay 80% (20/80) with 4k OOP max for in network charges for a 'single person', or 7.5k for in network family."
If your policy says you pay 20% and they pay 80%, shouldn't you (your wife to make it clear) pay $4K Out Of Pocket and then share that $295K (minus $4K OOP which you have paid earlier) bill with your insurance company, ie, she paying additional $58K and the insurance company the remaining 80%, which would be $233K?

3. "OUT of network, for us is 40/60 with 8k single person / 18k family. (after OUT of network OOP is maxed, its also 100% paid by insurance)."
Again, the same question as above. Since your OUT of network plan is : you pay 40% and the insurance company 60%, for a single person, after paying your $8K Out Of Pocket, shouldn't you be sharing the OUT of Network bill on 40% you and 60% the insurance company basis? Why would you be saying that after OUT of network Out Of Pocket is maxed, the insurance company covers 100% of the OUT of Network bill?

4. "I have no experience with 'self-employed' policies, it seems from your research some are not covered 'out of network', but do any exist which cover out of network for self employed?."
Very good question. As I said earlier, I am actualy surprised your insurance company covers OUT of network bills at all? I've always thought OUT of network meant exactly that, you are on your own, insurance company won't want to have anything to do with that.

5. "and also you have preened that some insurance companies refuse to pay, i'm glad for that and thank you for alerting me!, I will continue to build another fund to cover at least some of this potential costs. (and medical costs in general)."

That's what I have learned from watching all these videos on YT. I've always thought , if I ever wanted to move to the US, I would have to seriously make sure, that after getting my health insurance, I need to research which hospitals, clinics, are in and some out of network. I also thought , to make sure I am super safe , in this regard, if I ever got seriously sick, and had no time to chose which hospital I am going to be taken to, or even in case of being taken to IN network hospital, I would be having a large sign attached to my chest saying " only IN network doctors, nurses, specialist are allowed to work on me" haha.

There are plenty of videos that I have watched over the last few months, if you wanted me , I could paste them in here, for you and everyone else to watch , and hopefully learn a thing or two. We could also discuss them , and see what wet wrong and what else could have been done, to minimise the risk of being taken for a ride.

6. "Always a good idea, if at all possible if one of your family members could get a Job with healthcare provided , which can mean subsidized Insurance premium payments."
Yes, I've heard people employed in healthcare have the best health insurance, but I don't think any of us will ever be working in healthcare.
A few weeks ago, I exchanged a few messages with some american lady in her very early 60's who was commuting over one hour one way, to a job that was paying $15/hr only because the company provided a very good health insurance (Dallas area). Aparently 25% people living in Dallas have no health insurance, can't afford it.

7. "we have paid out premiums last yr about 4.5k , and paid the OOP max 4k = 8.5k last year on medical. This year we are paying more premium 5.8k and maxed our OOP both years , that's closer to 10k this year, i got have a tooth extracted soon, probably push us to 13k this year."

This sounds like a very well priced health insurance, $4.5K per year for a couple, sounds very cheap. Even $5.8K sounds very cheap. Would it be OK to ask you how much your emplyer contributes towards your health insurance?
If you both spend so much on your Out Of Pocket, have you ever thought about going abroad to do some none emergency treatments, say Mexico, Malaysia, or Eastern European countries, even anywhere in Blighty would be cheaper. The only thing which could have stopped you last year was Covid, I guess.
Also, what metal colour is your health insurance?

8. "we were billed randomly this year from an out of network provider which was a neuro-monitoring service during the OP last year!, we contacted the hospital and said we had an agreement everything would be 'IN network' , and that, this Bill is a year late. it was approx $9000 bill, they said they had to contract the OUT of network provider as it was the only service provider that could provide this planned service during the OP and the surgeon deemed it necessary, I respect the surgeon for making that decision, and subsequently, the hospital dropped the majority of the bill but still charged us around $128 or so, we just paid it."

How can they do that? You agree with them that all is going to be done on IN network basis, and then some unexpected OUT of network bills comes in? This seems to be a common occurence from what I am reading.
At least you had some humane people working at that hospital and they dropped it. $128 wasn't much to pay , in the end, in the whole scheme of things.
If you had to pay that OUT of network $9K bill, you would have had to pay $8K as your Out Of Pocket first and then the insurance company would have had to pay the remaining $1K?
Unless you had paid some Out Of Pocket bills earlier (in that same year), so that $8K out of pocket would have been reduced and the insurance company would have paid more. Am I right?
....but again, if you are sharing these OUT of Network bills on 40% you and 60% insurance company basis, you should have had to pay $400 and the insurance company $600, out of that remaining $1K. Confused.

9. "The in network out patient care my wife received after the discharge, which taught her how to walk again, was great!, and according to our policy we had some 60 therapy sessions covered (you need to read the small print in your policies over here, without question for example out patient therapy sessions), however, you still pay 20/80 IN network, and since another policy year for us has elapsed, this out patient care built up another years OOP max"

Yes, Understood that.

10. "you need to keep fit over here and not frequent bad heath habits."

That shouldn't be a problem, none of us smokes/ drinks, we enjoy the outdoors, exercising, keeping fit, so this should not be a problem, but bad things can happen to anybody, so a good health insurance is essential.

11. "Another tip is opening up a HSA account, (health savings account) you can save money pre tax, but you can only use it for medical expenses, otherwise you will pay the tax on it.
I then invest my saved monies (my particular HSA allows me to choose investments within the saved money)."

Yes, I have heard about them, and would be planning to have one or two well funded.
What can you invest your HSA funds in?
Can you use your HSA funds as a deposit to buy a rental property?
Can you borrow money against these HSA funds?
Is there a yearly limit of how much you can deposit into these HSA accounts?

Your post has been very helpfull.
Thank you for that.
I hope others could post similar stories, so we could all learn from them and discuss them one by one.

This video is an interesting one, about this new legislation which Olly mentioned earlier, so I did search on YT and found this:


One thing made me think, when at 04:15 she mentions about the patient being transfered from one IN network hospital to the other IN network hospital, and that made me think , what would have happened if the other hospital was OUT of network, she had no say in deciding where she was going to be transfered, and if it was OUT of network, she would have ended possibly bankrupt after being released from the hospital.

Need to go to sleep now. Will reply tomorrow. Cheers

SanDiegogirl

Wonder if John 23456 is doing some sort of research/thesis on the state of US healthcare?

Can't remember anyone writing and asking so many questions.

Olly_

Wow that post is a wall of text.

If you have a good job they will pay most of your premium. My husband works for a large consulting company - (high deductible) medical insurance costs just over $2000 per year out of pocket plus they contribute $1000 to a HSA. I believe they pay 85-90% of the premiums.

As far as I'm aware the metal color descriptors are only relevant to ACA marketplace policies, employer provided insurance is very different.

Depends on the custodian of the HSA, I have mine with Fidelity (no fees) and it works just like a regular brokerage account. I have most of mine invested in FZROX.
Only if you withdraw the funds by having medical expenses to offset or pay income tax and the penalty if you're under 65, so no not really
No
Yes, you can only contribute if you have high deductible insurance and the limit is $3,600 for an individual or $7,200 for a family. It's not a magic bullet, it's just another retirement savings account really.

hutchison

thankyou and please don't reply to yourself , shorten the posts (i'm guilty in that I gave you a lot of info) it will / has become convoluted.

• yes 295 - 4k (291) was the bill, insurance paid 291.
• try to understand it this way : to get to 4k, the first two bills they sent me were 10k each, of the 10k bills i paid 20% of, = (2k) twice; = 4k out of pocket (the max according to my policy)

insurance paid the other 16k (80%), those two 10k bills were part of the total of 295.

after those first 2 bills, i didnt pay anything more. (read that over and over) until it sticks.

• no idea how much employer pays.

robin1234

Multi-volume encyclopedia, I believe.

I just read about an orthodox Jewish rabbi in Brooklyn who recently died. He left his encyclopedia unfinished - he only completed the first nineteen volumes. He was still on the letter aleph (A.)

John123456

There is some guy in Instagram called Donald T snr ( I won't be revealing his full name as he might be a member in here watching this thread), aparently he said he was and still is some very important politician in his great home country of the USA.
He asked me if I could conduct a little research amongst British community living in the US, and ask some questions about their experiences with the US healthare, how happy they are with it and whether they understand the healthcare system of their new country.
He also said , his pal, had a pleaure of using the Scottish socialised healthcare and was very impressed.
Apparently he was and still is planning to run for a presidential office in 2024, and wants to know as much as he can about the subject as he is thinking of introducing the exact system in the US as people enjoy in the UK.
Not sure now, maybe he was just pulling my leg.

John123456

Now, one simple short reply and I understand it all. Makes sense now.
And I didn't even have to read it it twice.

So, say , if I was to follow the rules, buy health insurance, got cancer which aparently over 40% of us will be getting at least once in our life time, the treatement would be going over 2, 3, 4 years, with all these chemio and radio therapies, I would need to worry at all because I would be just paying my yearly Out Of Pocket expenses, and the insurance company will take care of the rest. Am I right here?

Are there any insurance companies that are to be avoided , or all of those selling premiums are fully reliable and trustable, and they will never refuse to pay any of my medical bills?

Thanks

scrubbedexpat099

I suppose it depends on how bad the Cancer is and if you can carry on working.

civilservant

They all do that. Filing an appeal is not abnormal.

Winston_the_Great_Dane

For all the expense incurred, I am very much happier with the quality of my healthcare provision here than the UK. The US should not try to emulate mediocrity. Is there a better way to manage US healthcare? Almost certainly. Is copying the NHS the right model? Almost certainly not.

John123456

I understand the quality might be better in the US, actually it is better, but only for those that are rich , have a lot of money to spend on this top quality healthcare.
The question is, what do you need to do to make sure your health insurance will pay for your health expenses, such as , say, cancer diagnosis, operation, and chemio, radio therpy for a few years afterwards.
These things are prohibitevely expensive in the US of the insurance company refuses to pay and you need to pay for it all out of pocket.
Do you have any advice for those that are stuck with monstrous bills because their insurance company refuses to pay?

John123456

Yes, I understand your point.
Even if you are with a good , reliable, trustworthy insurance company, in case of Cancer, you still need to be able to pay your monthly premiums, despite, perhaps , not being able to work, because of your condition.
Do many people have a short and long term disability insurance?
How expensive would that be?
I've read somewhere that each of them costs about 1 - 4% of your yearly wages.
So, say, you earn as self employed on 1099, $100K/year, your short term disability insurance would cost you , lets say 3% of your wages, which equates to $3K, and long term disability insurance also 3%, at $3K.
Mabe this could be the solution to making sure, even if you need to stop working , you still have that short and long term disabillity insurance, which should allow you to receive some money and allow you to keep paying your monthly/yearly insurance premiums and have enough money to meet your yearly Out Of Pocket expenses, have money to keep roff over your head and enough to keep the family fed.
Am I making sense with this kind of approach?

John123456

Here in the UK, as i am sure, you are all aware , there is a website called moneysavingsexpert.com, which I trust and I believe provides the most impartial advice on everything consumer related. Another one would be Which?.

Is there an equivalent in the US?
Is there an oragnization that regularly rates the most reliable, trustable health insurance companies in the US?

Thanks