Do you really know how your health insurance works?

[shipps]

I work as a Counselor at a hospital and we have been taking calls all day every day by people who just have no clue how insurance even works. They think if its Blue Cross Blue Shield they can use it at our hospital and it will be great!...Why?.....Well, because its Blue Cross and they are awesome! They have advertisement everywhere so they must be good.

 

Do you sit down and read the benefits? Do you understand In and Out of Network? The more I talk to people it appears a lot of people do not understand how their insurance really works and when the s*** hits the fan and it doesn't cover like they thought they are pissed.

[Iwritecode]

I think the only people that really know how insurance works are the people in the insurance industry. The rest of us just muddle along the best we can.

[StrangeSox]

Yeah, I know what my copays are for the regular doctor visits and prescriptions, not much beyond that.

[pettie4sox]

The rhetoric is definitely convoluted on purpose. I get my annual cleanings and physical and pray I never have to use my insurance beyond that.

[RockRaines]

I work as a Counselor at a hospital and we have been taking calls all day every day by people who just have no clue how insurance even works. They think if its Blue Cross Blue Shield they can use it at our hospital and it will be great!...Why?.....Well, because its Blue Cross and they are awesome! They have advertisement everywhere so they must be good.

 

Do you sit down and read the benefits? Do you understand In and Out of Network? The more I talk to people it appears a lot of people do not understand how their insurance really works and when the s*** hits the fan and it doesn't cover like they thought they are pissed.

Yes, but it took me paying a s***load out of pocket when I had my son to find out.

[shipps]

I see it happen so often to where people get screwed because they didn't read their benefits and the networks of where they can go. It doesn't take too long to find out a few basic things about your coverage.

 

1. What is the exact name of my policy and where can I go that is considered In-Network with my plan?

 

2. What is my deductible (because I will have to come out of pocket this amount until insurance pays)?

 

3. What is my Out of pocket Max?

This is the most you can come out of pocket after you have met your deductible. The percentage break down of this amount is your Co-insurance. Example 80/20 meaning the insurance company will pay 80 percent and you are left with the remaining 20 percent until you reach the Out of pocket max.

 

Your copay amounts really are the least of a concern because those are minimal. When you are utilizing your insurance out of network is when you really get screwed because your deductible winds up being thousands of dollars more and your out of pocket max is thousands more.

[Chisoxfn]

All of the above I know, but I also can go anywhere I want (knowing that if I do, my coverage goes down, but can). All that said, it still doesn't mean I understand what anything is going to cost, cause I have no idea what the hell the bill of any random procedure is going to be. None. I know what my insurance will pick up but it is a percentage (until you hit your out of pocket max) and what that baby is going to actually cost from the hospital stay, etc, who the hell knows. That said I work in finance and thus realize you need to read the fine print, but I'd also be the first to know that often times when you ask your insurance company you can often get a freaking complex answer that makes no sense (or potentially even the wrong answer).

 

Next time I'm in chicago, I'm visiting your desk and going to make an outburst...what do you mean I have to pay you money..I have insurance, that means its free.

[pettie4sox]

I see it happen so often to where people get screwed because they didn't read their benefits and the networks of where they can go. It doesn't take too long to find out a few basic things about your coverage.

 

1. What is the exact name of my policy and where can I go that is considered In-Network with my plan?

 

2. What is my deductible (because I will have to come out of pocket this amount until insurance pays)?

 

3. What is my Out of pocket Max?

This is the most you can come out of pocket after you have met your deductible. The percentage break down of this amount is your Co-insurance. Example 80/20 meaning the insurance company will pay 80 percent and you are left with the remaining 20 percent until you reach the Out of pocket max.

 

Your copay amounts really are the least of a concern because those are minimal. When you are utilizing your insurance out of network is when you really get screwed because your deductible winds up being thousands of dollars more and your out of pocket max is thousands more.

 

I understand the very basics of insurance. Those you listed I would say are the basics. That being said, I don't know how times I've followed all the rules and still ended up paying out of pocket for something. I had a routine physical and had to pay $100 for blood tests because it wasn't covered. This was pre-ACA but the sheer fact I had to fork over $100 for preventative care was preposterous!

[RockRaines]

I didnt realize that I had to pay 20% of my medical bills per my insurance for anything other than basic stuff, and my OOP max was high. My sons birth really brought this out.

 

SInce then I have moved into a high deductible plan that my company offsets with an HSA contribution. This plan pays 100% after my deductible is met.

[Chisoxfn]

I didnt realize that I had to pay 20% of my medical bills per my insurance for anything other than basic stuff, and my OOP max was high. My sons birth really brought this out.

 

SInce then I have moved into a high deductible plan that my company offsets with an HSA contribution. This plan pays 100% after my deductible is met.

At my company, all of the plans have you paying 20% till you hit your max. But it isn't like I know this hospital's birth will cost 10K and this one will cost $20K. All I know is somehow I think we paid like $6k for our son's child birth this year (paid a couple hundred bucks for the stupid bag they give you when you leave the hospital for pete sake). If I knew you get charged for that thing they leave with you, I'd have told them to take it (of course they probably would have charged me anyway). Think had a manual expressor pump, a onzie and a diaper bag...come on now.

[Iwritecode]

Semi-related story:

 

I took my daughter to a walk-in clinic to get a sports physical for school. I figured it would be faster and easier than scheduling an appointment and driving across town and waiting an hour in the waiting room to see our regular family doctor.

 

Then I find out the clinic doesn't even take insurance for sports physicals and I had to pay the $50 out of pocket right then and there. What kind of BS is that? They take insurance for other things though...

Edited November 20, 2015 by Iwritecode

[shipps]

I always assume I will be coming out of pocket max for that given year and if that's not the case then great.

 

Now in terms of going to clinic visits that don't except insurance for certain services, that can be really frustrating. It doesn't make any sense at all.

 

And if you really want to find out how much procedures cost you can. Every hospital has to have some sort of Financial Counselor that can look up in their pricing system of estimated costs. We particularly need a CPT code (procedure code directly related with the test or procedure) and we can pull up estimated costs in a matter of seconds. But most of the time its not even necessary because if you are having some sort of procedure you are going to meet your out of pocket max because they are usually expensive.

[RockRaines]

At my company, all of the plans have you paying 20% till you hit your max. But it isn't like I know this hospital's birth will cost 10K and this one will cost $20K. All I know is somehow I think we paid like $6k for our son's child birth this year (paid a couple hundred bucks for the stupid bag they give you when you leave the hospital for pete sake). If I knew you get charged for that thing they leave with you, I'd have told them to take it (of course they probably would have charged me anyway). Think had a manual expressor pump, a onzie and a diaper bag...come on now.

I really only used "basic" services before I was married so everything was 20 bucks for the co-pay. Its crazy how little I knew.

 

My current one is max of 4k deductible (my company offsets it by 1500 in an HSA) so the max ill ever pay for anything over basic services is 2500 bucks (and I use my HSA for that). I never would have thought about changing to that plan.

[LittleHurt05]

What I don't get is the whole insurance "discount" or reduction.

 

A doctor or hospital charges $10,000 for something, and the insurance just says, nope, you will take $6k and you will like it. How does that even happen on both ends? Uninsured people have to pay double, besides not having any coverage? It's all a scam I tell ya.

[StrangeSox]

What I don't get is the whole insurance "discount" or reduction.

 

A doctor or hospital charges $10,000 for something, and the insurance just says, nope, you will take $6k and you will like it. How does that even happen on both ends? Uninsured people have to pay double, besides not having any coverage? It's all a scam I tell ya.

Volume. Insurance companies can supply tons of patients, as an individual you can't. No different than getting a better price on a computer from Dell because I'm ordering 1000 than you could get ordering 1.

[StrangeSox]

Thanks for the thread though, shipps. Prompted me to go back and review what my plan actually is.

[shipps]

What I don't get is the whole insurance "discount" or reduction.

 

A doctor or hospital charges $10,000 for something, and the insurance just says, nope, you will take $6k and you will like it. How does that even happen on both ends? Uninsured people have to pay double, besides not having any coverage? It's all a scam I tell ya.

 

Thats the contractual agreement that makes the two sides In Network with one another.

 

Uninsured people get an automatic discount for being self-pay in pretty much every facility. Our patients who live in Illinois who are self pay get a 68% discount.

[shipps]

Thanks for the thread though, shipps. Prompted me to go back and review what my plan actually is.

 

Cool.

 

I figured since this is enrollment time its a great time to talk about it.

[StrangeSox]

 

Krieger: Damn-ass-hammer-s***! Benefits! Doh, I forgot to spend the balance in my goddamn flex account!“

 

Pam: Are you dated employment, or…

 

Krieger: Calender year!

 

Cheryl: Ouch.

 

Cyril: That’s just leaving money on the table, how’d you forget that?

 

Krieger: I guess I was busy fantasizing about Archer and Lana having intercourse!

 

Cyril: Ahh! (begins crying)

 

Pam: Cyril, c'mon hon. We all were.

 

These corporate bag munchers owe me $630 for my GODDAMN FLEX ACCOUNT.

[Y2HH]

I'll do my best to explain this.

 

1) The 800 number on the back of your card can be used to verify and/or answer any questions you may have.

 

2) The yearly deductible is what you will pay BEFORE insurance kicks in unless otherwise superseded by a listed co-pay. For example, if you have a 500$ deductible, but a 30$ co-pay for a office visit, for regular office visits you will pay the 30$, NOT the deductible.

 

3) The maximum out of pocket is what kicks in AFTER you've paid your yearly deductible, after this is reached, you are 100% covered for the remainder of the year.

 

4) This is where hospital charges or in/outpatient charges start kicking in. For example, if you were to break your arm, and the bill is $3500, you are responsible for 1) the deductible, which is $500. This leaves 3000$ remaining. Your insurance will then list a % you are responsible for, for example, 20%. So of that remaining 3000$, you are responsible for an additional 20% UP TO THE YEARLY MAXIMUM.

 

Charges are often separated by a in-network/out-of-network cost. You may see something similar to this: in-network/out-of-network office visit: 25$/40$. In this example, an office visit in-network is 25$, and that same visit to an out-of-network doctor would be 40$. The same goes for non-specialist/specialist: 50$/100$. In that example, a non-specialist would cost you 50$, whereas a specialist is 100$. What is a specialist? A dermatologist is a specialist for skin conditions, where as a general practitioner is just a regular doctor.

 

*** Keep in mind that ONLY FDA approved procedures and tests are covered. If there is an experimental test your doctor recommends, they SHOULD be telling you that insurance MAY NOT cover these charges, as they are not obligated to do so. That doesn't mean they won't, but they don't have to do so.

 

If you have an HMO, ANYTHING your PCP (Primary Care Physician) requests will be covered. Period.

If you have a PPO, you will be on the hook for anything uncovered (such as non FDA approved procedures).

 

If you disagree with a charge AFTER fighting it, and still do not agree with the insurance companies assessment, you can ALWAYS request the case go to arbitration.

 

Last but not least, keep in mind that if/when you cannot pay a bill, you CAN negotiate...and if they refuse to do so (they can), you can agree to make monthly payments and these "loans" CAN NEVER BE CHARGED INTEREST. If you owe 2000$, tell the hospital all you can afford to pay is $50 a month...they WILL let you interest free.

 

If you have any questions let me know.

Edited November 20, 2015 by Y2HH

[Jenksismyhero]

What I don't get is the whole insurance "discount" or reduction.

 

A doctor or hospital charges $10,000 for something, and the insurance just says, nope, you will take $6k and you will like it. How does that even happen on both ends? Uninsured people have to pay double, besides not having any coverage? It's all a scam I tell ya.

 

Pssh, more like $800. I've seen $30k ER charges "adjusted" down to $2800 before.

[shipps]

Pssh, more like $800. I've seen $30k ER charges "adjusted" down to $2800 before.

 

Medicare does this worse than anyone. Medicare tells the hospital what a procedure costs and there are no if's and's or but's about it. The hospital accepts that medicare rate that's not even close to what the actual charge is which they pay months later.

[kevo880]

Very thankful that this thread was started shipps! My wife will be coming off of her parents insurance in January so we are looking for plans for her. I am covered through work, but it doesn't cover anyone in my family. It doesn't seem like the best plan so I don't think it is worth the money to pay for her to be on that same plan. We are more than likely going to be starting a family in 2016 so I am focused on finding a plan that will allow us to spend as little as possible for all of the Dr's visits and the actual cost of having the baby at the hospital. I don't mind paying a higher than average monthly rate as long as it saves us money on those two things.

 

I am in sales for a living and one of my prospective clients is in health insurance sales and he started asking about my situation so I told him my wife needs coverage for 2016. We end up scheduling a conference call with him, come to find out what he is selling is not a part of the ACA. Does anyone have any knowledge about health insurance that isn't part of the Affordable Care Act? Specifically US Health Advisors is who he is with. I know by not going with an ACA plan there is a fee, but have any of you decided to go this route for your insurance? Other pros/cons?

 

It seems a little suspect to me, but I can't really pinpoint what about it that I don't trust. For those of you with knowledge on the subject, do you have any recommendations?

[Iwritecode]

I know by not going with an ACA plan there is a fee, but have any of you decided to go this route for your insurance?

 

I don't know of any fee. I get my insurance through my work and they have a plan that was grandfathered in so it isn't an ACA plan and I don't pay any extra fees.

 

[shipps]

Very thankful that this thread was started shipps! My wife will be coming off of her parents insurance in January so we are looking for plans for her. I am covered through work, but it doesn't cover anyone in my family. It doesn't seem like the best plan so I don't think it is worth the money to pay for her to be on that same plan. We are more than likely going to be starting a family in 2016 so I am focused on finding a plan that will allow us to spend as little as possible for all of the Dr's visits and the actual cost of having the baby at the hospital. I don't mind paying a higher than average monthly rate as long as it saves us money on those two things.

 

I am in sales for a living and one of my prospective clients is in health insurance sales and he started asking about my situation so I told him my wife needs coverage for 2016. We end up scheduling a conference call with him, come to find out what he is selling is not a part of the ACA. Does anyone have any knowledge about health insurance that isn't part of the Affordable Care Act? Specifically US Health Advisors is who he is with. I know by not going with an ACA plan there is a fee, but have any of you decided to go this route for your insurance? Other pros/cons?

 

It seems a little suspect to me, but I can't really pinpoint what about it that I don't trust. For those of you with knowledge on the subject, do you have any recommendations?

 

Be careful about going with a health care sales associates. In my opinion they have a biased and will push certain plans upon you instead of finding exactly whats in your best interest. So you are going to have to really ask a lot of questions and make sure there are giving you all options. As long as you keep with the basic fundamentals that have been posted in this thread you will be able to make an informed decision. Obviously make sure you find out the maternity benefits of the plan as well.

 

It MIGHT be a good idea to go outside of the ACA from what I am seeing now actually. Blue cross specifically changed all their ACA plans to Choice products. These products are Out of network with almost all of what people consider "good hospitals". If you have a Choice plan you will not have many options at all.

 

It appears that most of the plans that were offered in the ACA marketplace this year is changing next year to where contracting with In Network facilities are going to be extremely limited. The insurance companies are realizing it isnt financially beneficial for them at all to offer plans to this population so in order to stay in line they will still offer the ACA plans but no one is going to want them. Its ridiculous, but that is for the buster I suppose.