Our terrible health insurance

[Janeway]

The end result of this health insurance is..it is just bad. That dollar amount was a deductible to be met before they started to pay. The copays kick in after the deductible is met. I had a doctor appointment last week and had to pay just over $170. I am supposed to have a procedure next week, outpatient, and turns out, it is going to cost me $2500. I told them I thought there was just a copay and was told they checked with my insurance and the copay only kicks in after I meet my deductible. I am paying $900/month for this insurance.

 

Here is the real kicker. IF we had no insurance, we would pay the self-pay rate which is lower than the insurance rate. So it is costing us for not just the insurance, but also for higher visit rates as a result. Last weeks appointment would have been just under $100 if I was self-pay and the procedure next week would have been $2025.

[Catwoman]

I'm sorry you need to have the procedure, Janeway -- I hope everything goes smoothly and that your recovery is quick and easy! :grouphug:

[Janeway]

I'm sorry you need to have the procedure, Janeway -- I hope everything goes smoothly and that your recovery is quick and easy! :grouphug:

I need the procedure, but I had to cancel it. I won't be having it. Bottles of Ibuprofen and other painkillers and limiting my physical activity is cheaper than that cost.

[Tap]

Ask about self pay and then how to submit to the insurance yourself.   It can usually be done, you just have to have the right information (including itemized bill) from the MDs office and the correct form from the insurance company. 

[kewb]

Did you ask them if you could use self pay instead of insurance for the procedure?

[Scarlett]

I need the procedure, but I had to cancel it. I won't be having it. Bottles of Ibuprofen and other painkillers and limiting my physical activity is cheaper than that cost.

 

 

How much is the deductible?

[Catwoman]

The end result of this health insurance is..it is just bad. That dollar amount was a deductible to be met before they started to pay. The copays kick in after the deductible is met. I had a doctor appointment last week and had to pay just over $170. I am supposed to have a procedure next week, outpatient, and turns out, it is going to cost me $2500. I told them I thought there was just a copay and was told they checked with my insurance and the copay only kicks in after I meet my deductible. I am paying $900/month for this insurance.

 

Here is the real kicker. IF we had no insurance, we would pay the self-pay rate which is lower than the insurance rate. So it is costing us for not just the insurance, but also for higher visit rates as a result. Last weeks appointment would have been just under $100 if I was self-pay and the procedure next week would have been $2025.

  

I need the procedure, but I had to cancel it. I won't be having it. Bottles of Ibuprofen and other painkillers and limiting my physical activity is cheaper than that cost.

I'm sorry you decided to cancel your procedure, but you only started the thread five minutes ago and you said you were having it done and paying for it. :confused:

 

Have you spoken with the doctor and/or the hospital about setting up a payment plan so you can pay off the $2,500 in installments?

[Catwoman]

Ask about self pay and then how to submit to the insurance yourself. It can usually be done, you just have to have the right information (including itemized bill) from the MDs office and the correct form from the insurance company.

 

Did you ask them if you could use self pay instead of insurance for the procedure?

I was thinking the same thing, but the difference between the two amounts isn't huge and having the $2,500 go toward her insurance deductible could be a big advantage if she needs any more costly doctors' visits or procedures this year. Also, she might be able to negotiate with the doctor to get the $2500 discounted down to the self-pay amount. It would be worth a try.

Edited July 26, 2017 by Catwoman

[TechWife]

I've never known a traditional group health insurance plan not to have a deductible on most specialist visits and procedures, so I'm not suprised that this is the case. Do you have access to a quick reference guide that will tell you deductible amounts and what types of care are excluded from the deductible? My husband gets a link to one from HR every year. It's available online and we can access the information anytime.

[QueenCat]

The end result of this health insurance is..it is just bad. That dollar amount was a deductible to be met before they started to pay. The copays kick in after the deductible is met. I had a doctor appointment last week and had to pay just over $170. I am supposed to have a procedure next week, outpatient, and turns out, it is going to cost me $2500. I told them I thought there was just a copay and was told they checked with my insurance and the copay only kicks in after I meet my deductible. I am paying $900/month for this insurance.

 

Here is the real kicker. IF we had no insurance, we would pay the self-pay rate which is lower than the insurance rate. So it is costing us for not just the insurance, but also for higher visit rates as a result. Last weeks appointment would have been just under $100 if I was self-pay and the procedure next week would have been $2025.

 

It's pretty normal to have a deductible and need to meet it before you just do co-pays. It's been that way for us pretty much my entire adult life, so at least 30 years. With that experience, I can tell you that you can probably set up a payment plan, if needed. I'd do it with the deductible rather than self pay so that it counts for the year and reduces what you may pay later in the year, should something major come up, like an unexpected major illness or a car accident.

[Catwoman]

I've never known a traditional group health insurance plan not to have a deductible on most specialist visits and procedures, so I'm not suprised that this is the case. Do you have access to a quick reference guide that will tell you deductible amounts and what types of care are excluded from the deductible? My husband gets a link to one from HR every year. It's available online and we can access the information anytime.

:iagree:

 

Janeway starts a lot of negative threads on health insurance and while I understand her frustration, I'm not sure what she's expecting from her insurance company.

 

Deductibles are no fun and can be a hardship, but unfortunately they are to be expected.

 

I hope she decides to have her procedure done, because depending on the problem, things could get worse if she doesn't get it taken care of, and she could end up having to go out of pocket for a much higher amount later on.

[Butter]

We have *extremely* unusual insurance that pays the first thousand per person (we just pay co-pays for that part) and then we have a $1000 per person ($2000 family) deductible.  Under the insurance company's name, they even call it Coverage First.  They put right in the name that they kick in paying right away because it is so unusual.  I've never had insurance like that before.  In the past, we always had to meet the deductible first before we switched to just paying co-pays.  It really sounds like you have typical insurance coverage, Janeway.  The amount you pay really doesn't have much to do with it.  Most insurance plans are quite expensive and you still have to meet the deductible.  I've found providers are usually pretty good about letting you do a payment plan.

[DawnM]

If it is so much cheaper to not use insurance, just ask to pay out of pocket and not use it, but I honestly don't think it is.

 

My sons surgery was 2,000 or so for us but total was $30k for an outpatient surgery, I think insurance got it down to 18,000, but it still would've been massively more expensive to pay out-of-pocket

[SparklyUnicorn]

This is @$$.

 

 

[Janeway]

Ask about self pay and then how to submit to the insurance yourself.   It can usually be done, you just have to have the right information (including itemized bill) from the MDs office and the correct form from the insurance company. 

I did not know we could do this. Thank you! 

[Janeway]

If it is so much cheaper to not use insurance, just ask to pay out of pocket and not use it, but I honestly don't think it is.

 

My sons surgery was 2,000 or so for us but total was $30k for an outpatient surgery, I think insurance got it down to 18,000, but it still would've been massively more expensive to pay out-of-pocket

It is not a surgery, it is just a procedure. It is an injection in my back for my degenerated disk.

[TrixieB]

Ask about self pay and then how to submit to the insurance yourself.   It can usually be done, you just have to have the right information (including itemized bill) from the MDs office and the correct form from the insurance company. 

 

If your doctor is in-network with your insurance, the doctor's contract typically requires him or her to directly bill the insurance.

 

ETA:  if you don't want to use your insurance for a specific medical service, there is a form that the doctor's office will have you sign.  It states that you're agreeing to pay a specific $ amount for the service, that the office won't bill your insurance for the service, and that you won't submit the bill to your insurance for the service.

Edited July 26, 2017 by TrixieB

[mamaraby]

For my insurance the visit to the specialist has a copay, but if they do a procedure, then it is subject to deductible and coinsurance. When I looked into a pessary a few years ago, even though it was an in office type thing it was treated as a hospital type procedure.

 

I would not go self-pay. I would run it through my insurance because then I'd get their discounts. If you self-pay and then expect reimbursement, the insurance company is only going to pay what they would have paid. In that case, you could be out more money. So, run it through your insurance and contact the medical provider's billing office after the insurance pays and set up a payment plan for what you owe. That's how I'll be paying for the ER visit dh had last month. We couldn't afford it otherwise and his eyes are kind of important.

 

Your insurance souds pretty typical of i surance these days, tbh.

[Lang Syne Boardie]

1. Read and understand your policy so that you're not always surprised.

2. Negotiate the bill.

3. Run cost analysis on self pay v. paying down deductible.

4. For any health care expense, divert funds from luxury items such as fine furniture and vacations.

5. Consider setting up a health savings account, again, so health needs don't take you by surprise.

6. Educate yourself about health care in the USA, divert energy from complaining and self pity toward activism, and vote according to your conscience.

[Guest]

Like car insurance, health insurance is no longer for the small things. It is to pay for cancer treatment. Yes, it sucks and we need single payer.

[Mergath]

Yeah...? That's how health insurance works for just about everybody now. That's not terrible health insurance. It's pretty average from the sound of it.

 

If you don't want to jump through a bunch of hoops to get Medicaid, and you don't want to have to pay a deductible before your coverage kicks in, you should call your representatives and encourage them to push for single payer.

[Mergath]

I need the procedure, but I had to cancel it. I won't be having it. Bottles of Ibuprofen and other painkillers and limiting my physical activity is cheaper than that cost.

 

I'm so confused... you were at least briefly considering buying a $2k bed for a preschooler, but you're canceling a necessary medical procedure because it's going to cost around the same amount of money? :huh:

 

Since $2k obviously isn't a financial burden for you guys, why in the world would you choose to be in pain rather than have the procedure? Am I missing something here?

[AmandaVT]

Here are the BCBS plans in VT for comparison. There is one plan you can get for $900/month for a family. It's a crappy bronze plan with a$10,000 deductible and $14,000 out of pocket. After the deductible, the insurance only pays 50%. 

 

http://www.bcbsvt.com/wps/wcm/connect/312bad12-e87b-4ec3-a913-37af8ef3b503/2017-bcbsvt-qhps-quick-compare-group.pdf?MOD=AJPERES

 

I remember mentioning on your other thread that your health care benefits package isn't that bad. It's not a platinum plan, but it's decent. Set $$ aside each pay period into an HSA and you'll be able to pay most of your health costs through that, pre-tax. 

 

I have to pay everything, including my premiums, from our net pay, not pre-tax. 

 

Moxie's right - single payer would fix these issues for all of us in the US.

[QueenCat]

I'm so confused... you were at least briefly considering buying a $2k bed for a preschooler, but you're canceling a necessary medical procedure because it's going to cost around the same amount of money? :huh:

 

Since $2k obviously isn't a financial burden for you guys, why in the world would you choose to be in pain rather than have the procedure? Am I missing something here?

 

I concur.

[Sharpie]

Ask about self pay and then how to submit to the insurance yourself.   It can usually be done, you just have to have the right information (including itemized bill) from the MDs office and the correct form from the insurance company. 

 

I was told by our pediatrician it is illegal to do this in the state we live in.  You may want to triple check to make sure this is legal.  In our state, I was told that if I have insurance I can not self pay. 

[unsinkable]

I'm so confused... you were at least briefly considering buying a $2k bed for a preschooler, but you're canceling a necessary medical procedure because it's going to cost around the same amount of money? :huh:

 

Since $2k obviously isn't a financial burden for you guys, why in the world would you choose to be in pain rather than have the procedure? Am I missing something here?

A $2000 bed is a tangible object, that she is giving to her DD.

 

 

A $2000 procedure, that will only provide temporary relief, for herself, is different.

 

I know a ton of moms who'd buy their kids anything before they'd spend money on themselves, even a medical procedure.

 

Edited to add: But since she's not doing either one, it's a moo point. It's like a cow's opinion.

Edited July 26, 2017 by unsinkable

[Bambam]

I was told by our pediatrician it is illegal to do this in the state we live in.  You may want to triple check to make sure this is legal.  In our state, I was told that if I have insurance I can not self pay. 

 

I've also been told this.

 

As for the insurance, this sounds very typical to me. Different insurance policies = different costs, different payment plans (co-pay, deductible, out-of-pocket) - everything. Read them to understand what you have.

 

And, quite frankly, as someone with many friends who simply cannot afford insurance, be very thankful you can. We have a friend with young children facing a very scary cancer diagnosis and no insurance. 

[Scarlett]

I was told by our pediatrician it is illegal to do this in the state we live in. You may want to triple check to make sure this is legal. In our state, I was told that if I have insurance I can not self pay.

I cannot fathom how this can be correct.

 

I googled briefly and it seems like it might be that the doctor is under contract with an insurance company and that contract says the doc cannot accept self pay if the patient has that insurance.

 

But that is different than 'being illegal to self pay'.

[lauraw4321]

Since you have a high deductible plan, you should withhold money into a HSA.

[Erica in OR]

Does that "final" quoted cost include your insurance company's negotiated discount with the provider? When I receive the explanation of benefits from the insurance company after office visits, procedures, etc. have been sent to insurance, there are typically significant reductions in the cost, which impact how much I actually pay to the doctor for that visit or procedure.

 

Erica in OR

[Guest]

Not all high deductible plans are HSA eligible. Just FYI.

 

ETA--everyone still needs to save their deductible somewhere!

Edited July 26, 2017 by Moxie

[QueenCat]

Does that "final" quoted cost include your insurance company's negotiated discount with the provider? When I receive the explanation of benefits from the insurance company after office visits, procedures, etc. have been sent to insurance, there are typically significant reductions in the cost, which impact how much I actually pay to the doctor for that visit or procedure.

 

Erica in OR

 

That's pretty typical of my experiences too.

[Janeway]

Yeah...? That's how health insurance works for just about everybody now. That's not terrible health insurance. It's pretty average from the sound of it.

 

If you don't want to jump through a bunch of hoops to get Medicaid, and you don't want to have to pay a deductible before your coverage kicks in, you should call your representatives and encourage them to push for single payer.

adults don't get Medicaid where I live. Kids can be required to be on it, but no doctors or pharmacies take it so it can't be used.

[Guest]

adults don't get Medicaid where I live. Kids can be required to be on it, but no doctors or pharmacies take it so it can't be used.

If that is true (I still think you are mistaken) you should be contacting your state legislature to protest and demand a single payer system.

[Janeway]

A $2000 bed is a tangible object, that she is giving to her DD.

 

 

A $2000 procedure, that will only provide temporary relief, for herself, is different.

 

I know a ton of moms who'd buy their kids anything before they'd spend money on themselves, even a medical procedure.

 

Edited to add: But since she's not doing either one, it's a moo point. It's like a cow's opinion.

. Umm, wtf did you get the idea that I have ever bought a 2k bed for my daughter? Or even considered it??? You must be confusing me with someone else.

[QueenCat]

adults don't get Medicaid where I live.

 

I thought you live in TX. In TX, yes, certain adults can get Medicaid: adults caring for children, adults with disabilities, adults eligible for the Buy-In, and adults over 65. There are,of course, income requirements to be met but yes, adults in TX can get Medicaid. Actually, in ALL states, some adults can get coverage via Medicaid. And if I'm not remembering correctly, as to where you live, my apologies.

 

https://hhs.texas.gov/services/health/medicaid-chip/programs/medicaid-adults

[QueenCat]

. Umm, wtf did you get the idea that I have ever bought a 2k bed for my daughter? Or even considered it??? You must be confusing me with someone else.

NM

Edited July 26, 2017 by QueenCat

[Janeway]

I thought you live in TX. In TX, yes, certain adults can get Medicaid: adults caring for children, adults with disabilities, adults eligible for the Buy-In, and adults over 65. There are,of course, income requirements to be met but yes, adults in TX can get Medicaid. Actually, in ALL states, some adults can get coverage via Medicaid. And if I'm not remembering correctly, as to where you live, my apologies.

 

https://hhs.texas.gov/services/health/medicaid-chip/programs/medicaid-adults

yes, we live in Texas. But the income cut off for adults caring for children was a few hundred dollars. And even once you got it, only ERs take it for emergencies. Not regular doctors with appointments. Even unemployed with only unemployment for income, we did not qualify for this. https://yourtexasbenefits.hhsc.texas.gov/programs/health/young-adults-and-families

[Crimson Wife]

Not all high deductible plans are HSA eligible. Just FYI.

 

ETA--everyone still needs to save their deductible somewhere!

 

Most of them aren't unfortunately. Pre-Obamacare at least we could fully fund the deductible and out-of-pocket max through pre-tax money using our Flex Savings Account but Obamacare put a $2500 cap on FSA's. I am not in favor of Trumpcare but at least it would get rid of Obamcare's cap on FSA's.

 

[Janeway]

NM

go back and read the post for yourself. I said I would never spend that kind of money on a bed and certainly not a toy bed. The one I bought her cost $270 after tax and shipping and would allow us to not have a box because it was a platform bed.

[QueenCat]

yes, we live in Texas. But the income cut off for adults caring for children was a few hundred dollars. And even once you got it, only ERs take it for emergencies. Not regular doctors with appointments. Even unemployed with only unemployment for income, we did not qualify for this. https://yourtexasbenefits.hhsc.texas.gov/programs/health/young-adults-and-families

 

What you said was "adults don't get medicaid where we live". That is not the same as you not having qualified for it. Be glad you made too much at the time. And that you had savings during that period, which I remember you discussing having.

[QueenCat]

go back and read the post for yourself. I said I would never spend that kind of money on a bed and certainly not a toy bed. The one I bought her cost $270 after tax and shipping and would allow us to not have a box because it was a platform bed.

 

Yep, I did, which is why I removed my comment. I'm giving you that one, I was wrong on it. But not on the other stuff. But you said you returned that one because your little girl didn't appreciate it, so now you have that extra money to help with your medical bills.

[Janeway]

What you said was "adults don't get medicaid where we live". That is not the same as you not having qualified for it. Be glad you made too much at the time. And that you had savings during that period, which I remember you discussing having.

picking at my wording without bothering to say you were sorry for trying to tell everyone that I spent over 2k on a bed for my child? Regardless, even if I had spent over 2k on a bed for my child, that would have nothing to do with the original post, which was a follow up on interpreting information we were given about our health insurance last month.

[marbel]

I haven't read all the replies.  But I'm agreeing with the several people who have said that that's how a deductible works. 

 

We have a high deductible plan.  We pay everything out of pocket till we fulfill the deductible.  And then we pay a 10% coinsurance payment.

 

My kids get allergy shots, and twice a year we have to pay for the allergy extract.  It costs $800 per kid.  So, early in the year I have to pay a bill for $1600, all at once. (Actually I can usually stretch it out over 3 months, which helps.)  By the time the next refill comes around, we're down to the 10% coinsurance so I just pay $80 per kid and the insurance pays the rest. 

 

That's how it works.  It's a bummer when there is a big expense right at the start, that is true.  But look at it this way - you are closer to fulfilling your deductible.  If you pay outside insurance, you will still have that deductible to pay.  

 

ETA: Forgot to say that the cost of the extract before the bill goes to insurance is much higher than $800.  I've forgotten how much. The amount I pay the doctor (and which goes toward my deductible) reflects the rate negotiated between my insurance company and the doctor. That is always much lower than the doctor's initial charge.  

 

A typical specialist here charges $150 for an office visit; my negotiated rate through insurance (before I fulfill the deductible) is typically $70.  

Edited July 26, 2017 by marbel

[Mergath]

picking at my wording without bothering to say you were sorry for trying to tell everyone that I spent over 2k on a bed for my child? Regardless, even if I had spent over 2k on a bed for my child, that would have nothing to do with the original post, which was a follow up on interpreting information we were given about our health insurance last month.

What the heck was the point of that whole furniture post if you would never ever spend that much on a bed?

 

It's like you expect everyone to get selective amnesia when you post. I'm sorry, but it doesn't work that way. You ranted and complained about "being forced" to have Medicaid and offended the people here who use it. Now you're bitching and moaning about having the same employer insurance as everyone else. I really don't understand what you expect from everyone. If neither of those options are acceptable to you, start working toward pushing Congress to enact single payer coverage for the rest of us. Sign petitions, make phone calls, get out there and try to help make it happen.

[QueenCat]

picking at my wording without bothering to say you were sorry for trying to tell everyone that I spent over 2k on a bed for my child? Regardless, even if I had spent over 2k on a bed for my child, that would have nothing to do with the original post, which was a follow up on interpreting information we were given about our health insurance last month.

 

I did tell you that I was wrong........ and I'm NOT the only one who mentioned the furniture. But really, you have normal insurance. Stop acting like your situation is so much worse than the rest of us. It's not. If you're in that much pain, then make payments if you don't have the money on hand. But really, there are people on here with cancer, with kids with cancer, they are the ones who should be angry and livid about what they are having to endure.

[Catwoman]

. Umm, wtf did you get the idea that I have ever bought a 2k bed for my daughter? Or even considered it??? You must be confusing me with someone else.

  

picking at my wording without bothering to say you were sorry for trying to tell everyone that I spent over 2k on a bed for my child? Regardless, even if I had spent over 2k on a bed for my child, that would have nothing to do with the original post, which was a follow up on interpreting information we were given about our health insurance last month.

Wow. Nasty. :glare:

 

If you read unsinkable' post, she was DEFENDING you, and QueenCat already apologized for having made a mistake.

 

Maybe you're being nasty with them because you're angry that people aren't sympathizing with you about your insurance issue, but part of the problem might be that you have started so many threads complaining about both Medicaid and the cost of your husband's private insurance plan that people are losing patience for reading the same complaints over and over again.

 

Nobody likes to have to pay for health insurance. Nobody likes having to pay a deductible. But please try to be thankful that apparently you can afford to pay that deductible and that you are also able to afford to pay for your health insurance plan. Many people are not so fortunate.

[Butter]

yes, we live in Texas. But the income cut off for adults caring for children was a few hundred dollars. And even once you got it, only ERs take it for emergencies. Not regular doctors with appointments. Even unemployed with only unemployment for income, we did not qualify for this. https://yourtexasbenefits.hhsc.texas.gov/programs/health/young-adults-and-families

 

I live in Texas.  My boys' pediatrician accepts Medicaid.  My general practitioner accepts Medicaid.  These are regular doctors with appointments.  The income requirements are ridiculously low, though, making it very difficult for an adult to qualify.  That is true.

[Lang Syne Boardie]

It's a touchy time, janeway, for some of us to hear these complaints, because children we love are at risk of losing their health care coverage right now. This week. These past months. Forever? I don't know, it's an ongoing concern. They may be college students with preexisting conditions, or teens with cystic fibrosis whose care their parents could never afford.

 

So to whine about an average plan for lower priced treatment ($2k for a pain shot for an adult v. $14k for one month's meds to keep a teen alive)...it shows a lack of awareness.

[winterbaby]

You should have the procedure. You will end up having to pay the deductible sooner or later anyway and it is not worth being in pain and sacrificing function (and sitting around only makes back problems worse!!!) because you don't want to pay money that you apparently could pay if you wanted to. It seems, frankly, like this is motivated more by self-pity and a desire to play the victim than by financial prudence. As a person for whom, as it seems from your postings over time, this type of money is in fact discretionary, it doesn't come off well.