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Need help understanding insurance coverage?

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BargainMama
LIF Adult

Member since 5/09

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Re: Need help understanding insurance coverage?

Posted by PitterPatter11

Posted by BargainMama

Posted by PitterPatter11

Usually deductible plans do not have co-pays. I would assume the co-pay will be applied as partial payment once you get a bill.



All of the Healthcare Exchange plans have deductibles and co-pays, so I'm sure it's becoming more commonplace amongst other carriers as well.



Maybe they are moving towards this so they can guarantee some sort of payment - I am sure there are people who do not pay their bills and this at least insures the doctor gets something.



Healthcare exchange premiums are paid a month in advance, so if they are the type that don't pay their bills, they likely won't have insurance through the exchange anyway. It's not free, and definitely not geared toward those that don't pay their bills.

Posted 2/13/14 2:15 PM
 
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RubyWoo
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Re: Need help understanding insurance coverage?

Posted by Kitten1929

Posted by fins

If it works like mine, first you have to reach your deductible of $2,000. Once that is reached your co-insurance is 20% of the contracted rate.

For example if the dr. visit is $300 and your insurance company negotiated rate is $100 - you will pay $20 and insurance will pay $80

I am not sure why or how the co-pays work. We have deductible and co-insurance only



Thank you. I figured that was how the co-insurance worked, but I was thrown off by the co-pays AND deductible. I guess I will call back!




This is similar to how my plan works, except that whatever I pay in co-pays counts toward my deductible. Once I meet the deductible, I'll be responsible only foe the co-insurance, which I think is 20% , like yours.

Posted 2/13/14 2:25 PM
 

Millie3
LIF Adult

Member since 7/13

1280 total posts

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Re: Need help understanding insurance coverage?

Our insurance is similar, we used to have PPO but (huge, very profitable) company did away with it. We have a high deductible plan now.

So, DH went to the doctor for something, and had to pay the whole visit (think around 150). It becomes very painful during the winter with kid sick visits, plus our own visits. No copy, just have to pay straight up for the visit. If you paid a copay, it will be applied to your bill. You must meet the 2 K deductible before anything gets paid. Total BS!

Our ins was 800 a month for premium last year. This year, it's 250 a month BUT we now contribute to an HSA account, so we are still out that money and still have to pay these crazy Out of,pocket amounts.

It's very painful, it sucks, and it's becoming the new norm Chat Icon

Message edited 2/13/2014 2:42:03 PM.

Posted 2/13/14 2:38 PM
 

Blazesyth
*yawn*

Member since 5/05

8129 total posts

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Re: Need help understanding insurance coverage?

Posted by Millie3


Our ins was 800 a month for premium last year. This year, it's 250 a month BUT we now contribute to an HSA account, so we are still out that money and still have to pay these crazy Out of,pocket amounts.



You're not out the HSA money, it gets used towards your deductibles - and you get to contribute before taxes which is an advantage.

When you take a HSA insurance plan, you're basically gambling that you won't use it so you pay less monthly assuming you'll never actually have to pay out towards the deductible. For some, this works.

I feel like I'm at the doctor often, and I have some maintenance medications so I didn't take the High deductible option.

I'm sad to hear the OP is in this position, hopefully next year your HR team will explain it better to the employees.

Message edited 2/13/2014 2:54:51 PM.

Posted 2/13/14 2:46 PM
 

Millie3
LIF Adult

Member since 7/13

1280 total posts

Name:

Re: Need help understanding insurance coverage?

Posted by Blazesyth

Posted by Millie3


Our ins was 800 a month for premium last year. This year, it's 250 a month BUT we now contribute to an HSA account, so we are still out that money and still have to pay these crazy Out of,pocket amounts.



You're not out the HSA money, it gets used towards your deductibles - and you get to contribute before taxes which is an advantage.

When you take a HSA insurance plan, you're basically gambling that you won't use it so you pay less monthly assuming you'll never actually have to pay out towards the deductible. For some, this works.

I feel like I'm at the doctor often, and I have some maintenance medications so I didn't take the High deductible option.





Only because it's so early in the year, we don't have much $ in the HSA so we have to shell it out for now.

I really don't like HSA especially if you have kids, or a condition that needs to be treated. Unfortunately the PPO plan was done away with, we only have HSA to work with. I really miss PPO.

Posted 2/13/14 2:57 PM
 

jessnbrian
Only God knows His plan for us

Member since 4/13

7238 total posts

Name:
Jessica

Need help understanding insurance coverage?

$1900 annually is NOTHING, DH pays $500 per MONTH for just two of us - not even a family of 4 plan. We have $0 deductible for in-network, $2K for out of network, $20 copay for pcp, $30 copay for specialist, no referral required, and we only pay 10% of allowable rates for out of network. Many here already know I work in healthcare, so I am well versed in insurance and reviewed what DH was being offered. Keep in mind that's what we pay for premium, DH's company pays a lot as well on top of that.

Posted 2/13/14 3:24 PM
 

ISpoilHim
I think I got this

Member since 11/10

1523 total posts

Name:
K

Need help understanding insurance coverage?

Keep in mind that even though you have not met your deductible your insurance is still being used. They may not pay for the nutrients but if the contracted rate is lower at the pharmacy than you would pay without the insurance you still have a benefit. My son was on enfacare high calorie and we had a high deductible plan. It cost me about 250 for a months supply of ready to feed at cvs (6 cartons/6 cans per carton). At target it was about 15 a can. So it was a savings and the money I paid all applied toward my $12000 deductible (yes that's 12 thousand). Also going to the Dr if the Dr bills insurance $150 I generally only pay $50 of that because it is the contracted rate. That's almost the same as a copay. At times a high deductible sucks. This is all in addition to the $800 that comes out of my paycheck every month. But my son spent 7 weeks in the NICU when he was born and we paid nothing. His bills were enormous but once we met the deductible we are covered for everything.

Posted 2/13/14 3:31 PM
 

DrMeg
Back home!

Member since 5/08

1858 total posts

Name:
Meg

Need help understanding insurance coverage?

What you are paying now (before you reach your deductible) is not a co-pay. It is a negotiated rate you are paying towards services you receive before you hit your deductible. Once you reach your deductible you will be paying co-pays which are 20% of the service cost (that's the 80/20 co insurance).
For instance, if you went to the Dr before you met your deductible, the Dr may charge someone without insurance $400 for the visit. Your insurance has a negotiated rate of $200. You pay that $200 and now have $1800 left towards your deductible. If you had met your deductible your insurance would have paid $160 of that and your co-pay for your co-isurance would have been $40.

At least that is how my insurance works. My prescriptions also count towards my deductible, but that isn't always the case.

ETA: last month I paid $295 for a 30 day prescription. So yes, these High deductible plans stink. Now that I met my deductible I paid $12 for it this month.

Message edited 2/13/2014 3:54:27 PM.

Posted 2/13/14 3:52 PM
 

HillandRon
LIF Adult

Member since 5/05

2922 total posts

Name:
Hillary

Re: Need help understanding insurance coverage?

Posted by BargainMama

Posted by PitterPatter11

Usually deductible plans do not have co-pays. I would assume the co-pay will be applied as partial payment once you get a bill.



All of the Healthcare Exchange plans have deductibles and co-pays, so I'm sure it's becoming more commonplace amongst other carriers as well.



Not true, we are on a healthcare exchange plan, Health Republic and this was the only plan offered in Suffolk that does not have a deductible..... We do pay co-pays..... All exchange plans do not have out of network benefits.


Posted 2/13/14 4:18 PM
 

BargainMama
LIF Adult

Member since 5/09

15655 total posts

Name:

Re: Need help understanding insurance coverage?

Posted by HillandRon

Posted by BargainMama

Posted by PitterPatter11

Usually deductible plans do not have co-pays. I would assume the co-pay will be applied as partial payment once you get a bill.



All of the Healthcare Exchange plans have deductibles and co-pays, so I'm sure it's becoming more commonplace amongst other carriers as well.



Not true, we are on a healthcare exchange plan, Health Republic and this was the only plan offered in Suffolk that does not have a deductible..... We do pay co-pays..... All exchange plans do not have out of network benefits.





Okay 99% of them, sorry. PS, how is the plan? Are you finding that many doctors take it?

Message edited 2/13/2014 5:29:56 PM.

Posted 2/13/14 5:28 PM
 

pumpkinmom
LIF Adult

Member since 5/12

2911 total posts

Name:

Need help understanding insurance coverage?

Sorry your DS has a dairy allergy! I remember from another thread that you thought it was possible.
We have a similar plan, but without copays and our premiums are $6,000 a year. The year we had DD, we almost got to the maximum. But, on a normal year we might not even finish the deductible.
I think other posts explained, but I will anyway...if your visit has a copay, that should be all you pay. Otherwise, you pay 100% until you reach the deductible, then you pay 20% until you reach the maximum. The maximum should include the deductible. This is all in network. Out of network, you end up paying more because you also have to pay the amount above the reasonable and customary.

Posted 2/13/14 6:46 PM
 

Kitten1929
LIF Adult

Member since 1/13

6040 total posts

Name:

Need help understanding insurance coverage?

Thank you everyone for your replies. I realize that $1900 yearly is peanuts for insurance, but it's still a staggering amount to absorb when the deductibles are added in. I had the option of a buy-up plan but it was 1/3 of my weekly take home and they cut my pay as it was when I came back from maternity leave, which was at the same time as these insurance changes. I just worry that DS might need an even more expensive RX formula Chat Icon

Posted 2/13/14 8:02 PM
 

Kitten1929
LIF Adult

Member since 1/13

6040 total posts

Name:

Re: Need help understanding insurance coverage?

Posted by ISpoilHim

Keep in mind that even though you have not met your deductible your insurance is still being used. They may not pay for the nutrients but if the contracted rate is lower at the pharmacy than you would pay without the insurance you still have a benefit. My son was on enfacare high calorie and we had a high deductible plan. It cost me about 250 for a months supply of ready to feed at cvs (6 cartons/6 cans per carton). At target it was about 15 a can. So it was a savings and the money I paid all applied toward my $12000 deductible (yes that's 12 thousand). Also going to the Dr if the Dr bills insurance $150 I generally only pay $50 of that because it is the contracted rate. That's almost the same as a copay. At times a high deductible sucks. This is all in addition to the $800 that comes out of my paycheck every month. But my son spent 7 weeks in the NICU when he was born and we paid nothing. His bills were enormous but once we met the deductible we are covered for everything.



Thank you Chat Icon I will look int this!

Posted 2/13/14 8:04 PM
 

MorningCuppaCoffee
Tired!

Member since 12/07

16353 total posts

Name:
Allison

Re: Need help understanding insurance coverage?

Posted by Kitten1929

Thank you everyone for your replies. I realize that $1900 yearly is peanuts for insurance, but it's still a staggering amount to absorb when the deductibles are added in. I had the option of a buy-up plan but it was 1/3 of my weekly take home and they cut my pay as it was when I came back from maternity leave, which was at the same time as these insurance changes. I just worry that DS might need an even more expensive RX formula Chat Icon



I don't know if my previous comment got lost in the other posts, but again, check out Craigslist if the need arises. I bought from a woman who actually lived a few blocks from me who had bought the formula in bulk and then her child didn't need it anymore.

Also a lot of times the doctor will give you samples if it's a financial hardship.

Or throw it out on here. I've seen posts where people were selling formula.

Good luck!

The positive is they don't need to be on the formula forever, although it's hard to see the light at the end of the tunnel when you're going through it!

Posted 2/14/14 5:27 AM
 

jgl
Love my little boys!!!

Member since 8/07

7060 total posts

Name:
g

Re: Need help understanding insurance coverage?

Ugh I feel bad for you!

What bugs me too is if you dont have insurance or have to pay out first to meet deductable the dr will charge you $100. Meanwhile if you had insurance they accept you $20 copay and the $22 dollars the insurance pays them and thats it a total of $42 Chat Icon just not right!

Posted 2/14/14 7:31 AM
 

ISpoilHim
I think I got this

Member since 11/10

1523 total posts

Name:
K

Re: Need help understanding insurance coverage?

Posted by jgl

Ugh I feel bad for you!

What bugs me too is if you dont have insurance or have to pay out first to meet deductable the dr will charge you $100. Meanwhile if you had insurance they accept you $20 copay and the $22 dollars the insurance pays them and thats it a total of $42 Chat Icon just not right!



If you are paying the full $100 I would have a conversation with the office manager. I have been using a high deductible plan for 3 years now. I never pay at the time of service. The doctors office submits the claim and I pay only the contracted rate. This was drilled into us by the insurance company. Never any more. How would the doctor know what the insurance is going to allow at the time of service. A also if the doctor is not submitting the claim then the money is not being applied to your deductible. Always check your explanation of benefits and never pay more than what the insurance company says you owe.

Posted 2/14/14 7:38 AM
 

Lillykat
going along for the ride...

Member since 5/05

16253 total posts

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Re: Need help understanding insurance coverage?

Posted by Kitten1929

I have Cigna Open Access Plus In-Network insurance benefits. I have an 80/20 co-insurance. Individual deductibles of $2k each, family $6k. Out of pocket maximums of $5k each, family $15k.

What on earth does this mean? I have co-pays for DR visits, but how do I meet the deductibles? DS has a milk allergy and they will not cover the Nutramigen until his $2k deductible is met. At this rate, none of are going to meet out individual deductibles, and am I correct in understanding that there's ANOTHER $6k on top of that (or do our individuals constitute the family?). What does out of pocket maximums mean?

Sorry I am so clueless and I called and spoke to a rep with such a thick Southern accent I really could only determine that I need to reach DS' $2k before they will cover the Nutramigen.

I miss the good old days where insurance actually benefitted people. You could go to the DR and not worry about crazy deductibles and everything RX was covered.



You needs print out of your benefits. I don't think it is as crazy as it sounds. You shouldn't have a 2k AND 6k deductible. You need your benefits written out bc you don't usually have all the above at the same time. Some plans you pay the costs up to your deductible THEN the copay or co insurance.

So if you have 4 people in your family. You don't pay 2 then 6k. You pay up until either an individual meets the 2 k or you all rack up 6 k. So say mom pays 2k you would then switch to copay or coinsurance. Child 1 hit 2k so then you pay coinsutance or co pay. Then child 2 pays out 1k and dad 1k. Your deductible is met. You don't pay more than 6 k as a family or 2k for a single family member.

Then as far as co insurance or copay you won't pay more oop than eith 5k per person or 15k total. You will probable not hit oop max but if you do..you don't pay a dime more.

That is how they usually work but have seen plans where you pay a copay then are billed for the 20% of the coinsurance....that money goes towards reaching your deductible. Also have seen where you have copays for certain visits say sick visits but coinsurance for things like hospital stays, specialists or out patient procedures or blood work.

Message edited 2/15/2014 8:26:23 AM.

Posted 2/14/14 7:39 AM
 

Lillykat
going along for the ride...

Member since 5/05

16253 total posts

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Re: Need help understanding insurance coverage?

Posted by ISpoilHim

Posted by jgl

Ugh I feel bad for you!

What bugs me too is if you dont have insurance or have to pay out first to meet deductable the dr will charge you $100. Meanwhile if you had insurance they accept you $20 copay and the $22 dollars the insurance pays them and thats it a total of $42 Chat Icon just not right!



If you are paying the full $100 I would have a conversation with the office manager. I have been using a high deductible plan for 3 years now. I never pay at the time of service. The doctors office submits the claim and I pay only the contracted rate. This was drilled into us by the insurance company. Never any more. How would the doctor know what the insurance is going to allow at the time of service. A also if the doctor is not submitting the claim then the money is not being applied to your deductible. Always check your explanation of benefits and never pay more than what the insurance company says you owe.



This is not correct. With a high deductible plan you pay NOTHING at the visit. The office bills you, then you check the EOB to make sure it matches bc you pay the rate the INSURANCE Company would pay which is their allowable and contracted rate not the rate someone without insurance pays. Basically you are just paying them as if you are the insurance company. You should never pay at the visit because the dr might charge for something insurance song pay or a different amount. There should therefore be no "failure to pay a copay" fee bc some people have no copay. The office is supposed to be billing you so if you have paid fees for not paying copay at visits call and demand they reimburse you those fees!!

Posted 2/14/14 7:53 AM
 

jgl
Love my little boys!!!

Member since 8/07

7060 total posts

Name:
g

Re: Need help understanding insurance coverage?

Posted by Lillykat

Posted by ISpoilHim

Posted by jgl

Ugh I feel bad for you!

What bugs me too is if you dont have insurance or have to pay out first to meet deductable the dr will charge you $100. Meanwhile if you had insurance they accept you $20 copay and the $22 dollars the insurance pays them and thats it a total of $42 Chat Icon just not right!



If you are paying the full $100 I would have a conversation with the office manager. I have been using a high deductible plan for 3 years now. I never pay at the time of service. The doctors office submits the claim and I pay only the contracted rate. This was drilled into us by the insurance company. Never any more. How would the doctor know what the insurance is going to allow at the time of service. A also if the doctor is not submitting the claim then the money is not being applied to your deductible. Always check your explanation of benefits and never pay more than what the insurance company says you owe.



This is not correct. With a high deductible plan you pay NOTHING at the visit. The office bills you, then you check the EOB to make sure it matches bc you pay the rate the INSURANCE Company would pay which is their allowable and contracted rate not the rate someone without insurance pays. Basically you are just paying them as if you are the insurance company. You should never pay at the visit because the dr might charge for something insurance song pay or a different amount. There should therefore be no "failure to pay a copay" fee bc some people have no copay. The office is supposed to be billing you so if you have paid fees for not paying copay at visits call and demand they reimburse you those fees!!



Sorry you are righti meant this for people with no insurance

I remember working in a chiropractirs office and shed charge $50 for no insurance but most of the time with insurances and copays she never get $50

Posted 2/14/14 8:22 AM
 

BlueDiamonds
mommy to 3 boys

Member since 2/07

3885 total posts

Name:
proud mommy

Re: Need help understanding insurance coverage?

I also have the same Cigna plan as you, just different co-pays and deductibles. Had the plan last year as well. This year my company raised the deductibles and made other changes. What I can tell you is, every plan is set up differently so what one person on here tells you, might not be the correct information. I had to go over every detail with my HR before I completely understood. This is how my plan from last year worked (with co-pays, deductible and co-insurance), but may not be the same as yours.

Well visits, vaccinations, preventative care = 100% coverage, no co-pay, nothing towards deductible

Sick visits, specialists office visits, ER = set co-pays as shown on my insurance card. Did not count towards my deductible.

Everything else (procedures, hospital stays, medical supplies like my son's nebulizer machine) = deductible first using Cigna's negotiated rates, then co-insurance beyond the deductible using Cigna's negotiated rates up to the yearly maximum

Now he's the confusing part. I have the family plan (3 of us). Last year, the deductible was per individual and 2 people with met deductibles filled the family deductible requirement. So let's say you have 1 family member that racks up a lot of bills, their individual deductible would be met but they could not meet the family deductible alone and if someone else then had expenses, they would still have their individual deductible to meet. Once 2 individuals met their deductibles, the other family members did not have to meet theirs. My company changed this policy for my plan this year. Now, we only have a family deductible that must be met.

It's all very confusing with co-pays, co-insurance, deductibles, etc. And each company can set up the plan with different rules (what counts towards deductibles, how the deductibles, work, etc). To be honest, I have gotten incorrect information from Cigna regarding my plan on several occassions. Now, I ask my HR and call Cigna to tell them my plan!

Posted 2/14/14 11:49 AM
 

Xelindrya
Mommy's little YouTube Star!

Member since 8/05

14470 total posts

Name:
Veronica

Need help understanding insurance coverage?

not sure if it was said but I do believe your 2k is part of the 6k. We have 3500 indiv and 6000 family (yes its cheap, which is why my ded is high) but that 3500 counts to the 6000. I then have an HRA that I fund for (ta da) $2500 so that my actual post tax out of pocket is only $1000 generally as we hope never to break that first deductible. Better I get to roll over my HRA so I funded it last year for 2m and built a little bit in.

My whole insurance scenario is based on tax free funding of my ded. LOL but I am definitely High Deductible. Yes I pay for all doctor visits and Rx but I fund for that. I just started a new job so its painful at first but next year will be smoother. After I hit my deductible I pay 10% so its not that bad.

Every year so far we've had some rather high priced procedures. I although I always hope for none, I won't be surprised if we do again this year. Last year was AJ's surgery and my Brain MRI along with lung CT. This year is my dental (which isn't medical) but here's to hoping the family stays healthy, right? *crosses fingers*

Posted 2/14/14 6:11 PM
 
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