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I am flabbergasted.....Healthcare/ Insurance related (probably JAWM)


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This will be full of crass talk about money so look away if you must

Before getting pregnant my dd had 2.5 part time jobs.  One with the local public school as the reading specialist where she worked 1 hour less than they would be required to give her benefits, another job with the same public school running the after school program, again no benefits and the .5 being the  2 hours/ day from 4-6am she spends online teaching English to kids in other countries.

Her husband worked the maximum allowed 28 hours/ week on campus while finishing his Masters.

Because she is turning 26 in June and thus will be off our insurance which only offers her emergency services because she is in another state, she went to the exchange and got on a plan that costs her just over $400/ month.  Just her, as her husband pays $500/ semester at the school for his insurance.

Fast forward to today and she is pregnant with twins and in the hospital for the next 6 weeks until the babies are born.  The nice insurance person came in today and told them that the cost for her to stay in the hospital is $8K/ day (!) but her current plan has an OOP cap of $6K/ year......wait for it....per person, so when the babies arrive it will be an additional $6K/ baby.  The woman told her to apply for Medicaid and everything would be covered.....wait for it.....unless her husband got a job.  Even a part time job at the grocery store, if he makes more then some ridiculously low amount then they would lose the Medicaid and have to re-enroll in another insurance.   The woman told them if they qualify for Medicaid, then their best bet is for her husband to not get a job until the babies are born and out of the NICU.

But who is going to pay their rent?  Their bills?  They have some savings but not enough for months of no income.

aaarrrggghhh

OK,

I am better now

Amber in SJ

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If this was the lady who works for the hospital, have her call the actual insurance company and double check.  I can’t tell you how many times the hospital person has interpreted/flat out wrong on things they have “checked” with the insurance company.  Last hospital stay for DH, I had printed out what was and was not approved/allowed on the plan.  They did try to collect on something there that I knew had 100%coverage.  When presented with the paperwork and a phone call, they finally admitted that they don’t know everything.  

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14 hours ago, itsheresomewhere said:

If this was the lady who works for the hospital, have her call the actual insurance company and double check.  I can’t tell you how many times the hospital person has interpreted/flat out wrong on things they have “checked” with the insurance company.  Last hospital stay for DH, I had printed out what was and was not approved/allowed on the plan.  They did try to collect on something there that I knew had 100%coverage.  When presented with the paperwork and a phone call, they finally admitted that they don’t know everything.  

We had this happen too. When dd2 was in the hosptial with pneumonia the billing lady came to our room harassing us to pay RIGHT then that we owed so much money. I didn't want to pay b/c I figured they were wrong. Dh went ahead and paid and what do you know the amount they said we owed was way more than we actually owed. In the end I ended up having to call them every day to get my money back from where we over paid. Never trust hospital billing.

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I’m sorry. I hate how all of this works.

That said, all of the insurance policies I’ve dealt with over the years have their per-person deductible, and then they have the family deductible which is typically around 2x the individual. Not that I’m sneezing at 12 grand, but it’s less than 18.

The babies might be able to be covered by Medicaid even if her dh works, though I know all that varies by state. My sister’s babies were able to at some times, though not others.  It’s a horrible system we have.

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Have her find out what both the individual and family out of pocket maximums are - they will come into play.

After she meets her deductible, she pays the copay amount up to the individual out of pocket maximum. Once that individual out of pocket maximum is reached, she will pay nothing for covered services.

Each baby will have their own deductible to meet and will have their own individual out of pocket maximum as well.

The family out of pocket maximum combines the amounts paid on all people on the family policy. Once the family out of pocket maximum is reached, then all allowed/covered services will be covered by the insurance at 100%.

With such a long hospitalization, it is entirely possible she will reach the family out of pocket maximum before the babies are born.

Medicaid will pay the deductibles and copays up to the out of pocket maximum, as well as for any services that the insurance doesn't cover, but Medicaid does cover.

The bills will be processed as they arrive at the insurance company, so there's no way to tell ahead of time which baby will reach the maximum first if the family OOP maximum hasn't been reached.

When the social worker says if they apply for Medicaid, everything will be covered, it's because she knows that the family qualifies for Medicaid. She has already done the background work. She also knows that they are close to the qualification limit, which is why she advised him to not get a job until after the babies are born. However, have your daughter ask exactly what the income limit is for a family of two and a family of four. She should also ask about WIC and SNAP. She may not get WIC until after the babies go home from the hospital since she is currently hospitalized. If she happens to be discharged before the babies come, she should ask about WIC then. SNAP may help meet her husband's needs as he isn't getting meals from the hospital. The hospital social worker can help them with all of this.

Make sure, on the day that the babies are born, they are added to the insurance policy, even if they do not yet have names. The providers will start billing right away. Make sure she expects to get bills from the anesthesiologist if she has an epidural or a c-section, the ob/gyn,and the pediatrician that are in the delivery room. Then there will be a daily charge for the NICU for each baby as well as charges for individual providers, supplies, procedures and equipment. If anyone has surgery, there will be additional anesthesiology charges as well as surgeon charges and OR charges.

One rule of thumb is to keep track of services as they happen, but in all honesty, people who say that haven't had to keep track of one critical care situation, much less multiple critical care situations. Things will happen that neither she nor the father will remember, medications and treatments will be given when they are not there and things may happen very, very quickly.  It is the nature of the situation. She should not ever feel guilty for not remembering something. Tell her not to worry about keeping track herself in the moment, but when she receives a bill she should request an itemized bill. If the itemized bill has charges that don't seem right to her, she can request the medical records and compare them, or ask the hospital to audit her bill and provide the documentation for each charge to her. The babies getting appropriate care is what is important, the hospital can justify their charges to her later.

What a broken, broken system we have when working leads to financial punishment when it comes to medical care.

 

Edited by TechWife
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