Stupid Health Insurance Coverage Question

[Pamela H in Texas]

So, a month ago, hubby got hired on to the company he has been working for for the past year. THis means we have benefits. They actually start today :) Anyway, so I desperately want to get to the doctor (need thyroid and estrogen medications). I'd also like to check into a few things.

 

Okay, so I'm looking at the benefit chart and don't understand completely.

 

It says the per person deductible is $600

and the per family deductible is $1200

 

Then it says office copay is $30 (seems awfully high!)

 

So do I have to pay full price for visits til I get to $600 then will pay "only" $30?

 

For the littles, it won't matter as much as they will have Medicaid as secondary so it'll pick up everything. But for me, I need to know before I go to a doctor how much I'll need to pay because that will determine when I get to go, even if I get to go.

[Mama Geek]

You will only pay the copay for the office visit.

[Butter]

It depends. Is the deductible for in network as well as out of network? You might have to just pay $30 or you might have to reach the $600 first. If you call the number on your card they can explain it. $30 is a pretty good co-pay for office visits nowadays, sadly.

[momto10blessings]

We pay our $20 copay at the doctor visit. Then the doctor will send a bill for the visit. If the doctor charges $150, but the insurance companies allowable amount is $80, we send the $80 in then keep going until we reach the deductible. After we meet the deductible we are still responsible for 20%. For routine visits/well checks we pay the copay but the rest is covered.

[itsheresomewhere]

Let me help you feel better-

 

co-pay for non specialist- 50

co-pay for specialist-75

family deductible- 5,000

 

Your deductible and co pays are very reasonable.

[Pamela H in Texas]

Our last insurance had no deductible and we paid 10% of the contracted amount so Dr visits were usually under $20, sometimes way under.

 

I'm still confused. But it does sound more positive than before I asked :)

[NoPlaceLikeHome]

Make sure you go to docs and labs and hospitals that are in network since it is cheaper. With some pans when you go out of network, it can cost an arm and a leg. Individual deductible means you will only pay $600 max out of pocket, not including co-pays. However, if someone else in your family uses $1200 of the family deductible before you reach your individual deductible then you will not have to worry about deductible anymore. There should be a one sheet summary of all of your co-pays, deductibles, co-insurance, etc. with your insurance packet that is in simple laymen's terms. Also, your husband's human resource personnel should be able to help answer any questions as well as the insurance company.

[LMA]

Copays generally do not count toward the deductible. The max deductible is $600 for a person, but when you hit $1200 for the year for the family, you don't have to pay anymore toward the deductible. However, a lot of insurance companys have co-insurance either concurrent with the deductible or after the deductible. Therefore, you could be paying out of pocket after hitting the deductible.

[Lisa in Jax]

Pamela,

 

Many times, annual physicals/exams are covered at 100% (or with only the cost of the co-pay). If you can get your gyn/GP to Rx the meds at the same time as your annual pap or physical, the visit is likely to be covered 100%. Future checkups (i.e. if you go back within the next year) will likely cost you $30.

[Pawz4me]

Pamela,

 

Many times, annual physicals/exams are covered at 100% (or with only the cost of the co-pay). If you can get your gyn/GP to Rx the meds at the same time as your annual pap or physical, the visit is likely to be covered 100%. Future checkups (i.e. if you go back within the next year) will likely cost you $30.

 

^^This.^^

 

Although do be aware that if your doctor orders any blood work or other testing done then your deductible likely will come into play.

[Acorn]

You will only pay the copay for the office visit.

 

Depends on details in the plan. We have to pay the family deductible (4000) first, then we have office visit for the copay fee. Now, if your plan is part of the Obamacare deal, then you get well visits, pap smear, and other preventative things covered with no copays

[xixstar]

For my plan. If it is not a routine checkup (which are covered 100%), then we pay out of pocket for the allowed amount until we reach our deductible of $2,400 or something like that. How that works in reality is: the doctors office wants the copay amount at time of visit ($30) and then will send in the bill to insurance and we pay the bill once we get our EOB that lets us know exactly what we owe. I have tried to pay doctors in full at each appointment but they always want to wait until insurance gets back to them.

 

It works this way because the 'allowed amounts' (assuming in-network) seem to be so variable for each insurance plan, so the doctors office doesn't really know what I owe at the time of visit. So the doctor will charge $250 but the plan only allows $150 and so the doctor has to take the $150. So I would have to send in another payment for the remainder of the bill ($120, because I already paid $30 at the time of visit). It will work that way until I reach my individual deductible or our family reaches the combined deductible.

 

If and when we finally meet our deductible, something we've never done. Then we would just pay $30 copay for each visit.

[prairiewindmomma]

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[Pamela H in Texas]

I thought about going to the obgyn knowing he would prescribe the thyroid meds (though I'd rather get some changes on that). I owe him a balance from my hysterectomy 15months ago, but.....

I thought about going to the endocrinologist. Then I could mess with the thyroid meds; but I'm not sure she'd order the estrogen.

 

Then there is the cost of labwork as I really need a bunch of stuff done.

 

Decisions decisions.

 

ETA: Not that I'm deciding whether or not to go at all, just the whole "when" of everything. I also need major dental help. New insurance for that is $2000/year so if I did $2000 by the end of the year, I could get $4000 by the end of Jan/Feb.

[Garga]

Call your health insurance company. They will know whether you have to pay the deductible and then the copay, or whether office visits are copay only.

[vonfirmath]

So, a month ago, hubby got hired on to the company he has been working for for the past year. THis means we have benefits. They actually start today :) Anyway, so I desperately want to get to the doctor (need thyroid and estrogen medications). I'd also like to check into a few things.

 

Okay, so I'm looking at the benefit chart and don't understand completely.

 

It says the per person deductible is $600

and the per family deductible is $1200

 

Then it says office copay is $30 (seems awfully high!)

 

So do I have to pay full price for visits til I get to $600 then will pay "only" $30?

 

For the littles, it won't matter as much as they will have Medicaid as secondary so it'll pick up everything. But for me, I need to know before I go to a doctor how much I'll need to pay because that will determine when I get to go, even if I get to go.

 

Our office copay is $35.

 

The deductible for us only kicks in for hospital stuff. For doctor's office, we just pay the copay. It is possible there would be stuff in the doctor's office that would end up being a deductible.

 

Our per person deductible is much higher though -- and then we pay 20% afterward too.

[StephanieZ]

You might have to pay your $600 before coverage kicks in. BUT, thanks to the ACA, many preventative services and well visits are NOT subject to the deductible and generally don't even cost co-pays. Once that aspect of the ACA kicked in a year or two ago for us, we no longer pay co-pays at wellness visits at all.

 

If you could schedule a well-woman visit with someone who is good at endocrinology, they could likely order your labs as wellness care, too, maybe. So, you might be able to get what you need done w/o hitting to deductible. In any event, I'd expect a big family to hit the $1200 in a year most times, so I'd just try to squeeze it out of my budget and go take care of yourself.

 

Congrats!!! Yay, benefits!!

[Alessandra]

 

This really depends on your plan. We have a deductible and copay (and coinsurance). Some stuff is not subject to the deductible. Regular office visits to a general doc does not have a deductible. So we pay a copay only. Some stuff has a copay and coinsurance. Meaning they don't cover it 100%. So you pay a copay upfront. They submit for payment and if it wasn't covered 100% they send you a bill for the rest. Every type of service is different.

 

If your plan says flat out just $600 deductible and $30 copay then yes that is what it is. You will go and pay the $30 up front. Then whatever is not part of the $30 that the insurance covers and pays the doctor will count to the deductible (and they will send you a bill for the amount you have to pay). It's not usually the amount the doctor bills. It is the contract amount. So, for example, if the doctor sends the insurance company a bill for $200, but the contract is $100, you will pay $100, not $200. And most of the time that is not up front. The copay is always up front.

 

HTH

 

:iagree:

 

Wendy put this very well.

 

The only thing I didn't see in previous posts is whether or not you are covered for pre-existing conditions right now. Sometimes there is a wait before you qualify for benefits for pre-exisitng conditions.It sounds as though you haven't had insurance for awhile?

 

Usually, you can get a copy of your plan documents from HR/Personnel and/or check an online resource. Doctors offices can also be helpful. For example, I remember having a plan that covered two separate tests, but ONLY if they were done at different visits -- that sort of thing.

 

You also mentioned prescriptions. Your plan will probably have some sort of formulary with different tiers (usually 3 or 4 or 5). Prescriptions can be covered at varying rates, depending on the tier.

 

Btw, you co-pay and deductibles are great for today's world!

[Alessandra]

double post

[TranquilMind]

I thought about going to the obgyn knowing he would prescribe the thyroid meds (though I'd rather get some changes on that). I owe him a balance from my hysterectomy 15months ago, but.....

I thought about going to the endocrinologist. Then I could mess with the thyroid meds; but I'm not sure she'd order the estrogen.

 

Then there is the cost of labwork as I really need a bunch of stuff done.

 

Decisions decisions.

 

ETA: Not that I'm deciding whether or not to go at all, just the whole "when" of everything. I also need major dental help. New insurance for that is $2000/year so if I did $2000 by the end of the year, I could get $4000 by the end of Jan/Feb.

 

 

You know, there are low cost labs where you can get all this done far cheaper if you just pay cash. There are doctors working this way now too.