DH's new insurance policy (YAY!) is kinda confusing me. It says: Annual deductible In network $200 PP $400 max per family **my MD is IN network** Annual out-of-pocket maximum (includes deductible, coinsurance) In Network $1,500 PP $3K maximum per family. What does this mean to me if I have a surgery that is only covered at 80%?? Do I pay the full 20% difference or $200 or $1,500? I know the insurance co. will know, but THIS plan doesn't go into affect until 1/1/03 (new ins co.) and I'm very impatient...
Ya if it says it will only cover a certain % then you are responisible for the left over %. My health insurance only covers 80% for some sort of surgery also.
You pay the FIRST $200...then 20% of each bill up to a max of $1,500... If you have a family of say 5...then you pay the first $200 for the others in the family (if you already used the first $200)...then you pay 20% of all the bills till you reach $3,000 THEN YOU PAY NO MORE...TILL THE YEAR ENDS...THEN IT STARTS ALL OVER...
one last question... 20% of each bill up to $1,500 EACH bill OR 20% of each bill TOTAL $1,500 PERIOD? Surgery will be $25K (roughly) can I expect pay $5K or $1500?
Ok I called the insurance company... I pay my deductible (and my co-pays DON'T count) So I pay $1500 for me THEN the insurance company pays 80% then *I* pay the remaining 20%.... Bottom line, this ins. company suxx. For a $25K surgery I will pay: $1500 and all copays and such $5000 for *my* 20%.... UGH!
The way the policy was quoted at the top of the post, you would pay the first $200 plus 20% of remaining charges UNTIL your total out-of-pocket equals $1,500. Call the ins co again and speak to another rep to be sure. Sometimes you get incorrect info. Good luck.
I agree with Zaxxon. Call back and speak to someone else. I've never heard of an insurance company that works the way you've just described, so I bet the rep you spoke to was just confused <g>
Somebody is confused. Out of pocket is just that. You will not pay out of pocket more than $1500 for one person, or $3,000 for the whole family. for in network services. If you pay $1500 first, then they pay 80%, the $1500 is a deductible. Two different animals.
Kellie, Breeze and several of the other posters in this thread explained correctly how your co-pays and deductibles should work. That having been said, I want to reply from a different angle here, since I have medical insurance coverage that works similarly to yours and have run into issues that you'll need to be aware of. You most likely have either a PPO plan (Preferred Provider Organization) or a "traditional" indemnity plan. Once you start using this plan, you most likely will get explanations of benefits from your insurer as they process claims from doctors, hospitals, etc. (but not from pharmacies, except for durable medical equipment, assuming that your coverage has a rider for such equipment). Some companies (my insurer is one) will allow you to view EOB's over the Internet via secure server connections, aka "https". In whatever format you view them, they will explain the following important items: 1) How much the provider billed them; 2) The amount of the bill that the provider is supposed to write off as their "discount" for participating in the plan; 3) The amount of the bill after deducting the discount; 4) The amount actually paid to the provider along with the percentage rate from #3 above at which they were paid; 5) The amount you are responsible to pay; 6) How much of your co-pay and deductible responsibilities have been used and how much remain; 7) Explanations necessary to understand any of the amounts (most often I've seen these for the negotiated discount amount). When you get dr bills under a plan like this, compare them to any Explanations of Benefits your insurer will send you. Sometimes providers will try to "balance bill" you, meaning that they will bill you for the entire amount not paid by the insurance co, including the negotiated discount. I speak from very recent experience about this, as I am waiting to hear from my insurance co how they intend to deal with several of their in-network providers who are balance billing me for amounts that are not my responsibility to pay per the insurer. Should you be "balance billed" under such a plan, contact the insurer immediately and ask to speak to a supervisor. It may also be helpful to let your employer's benefits department and/or insurance broker know about these types of shenanigans. HTH, John
John- Thank you, and Breeze and everyone else thank you as well! I do have a PCP, I've never had one before and they kinda stink. I noticed they only cover 80% of having a baby (not that I want anymore), but I just thought most all ins. companies were 100% covered for that. I will definately keep an eye out for balance billing, the company they are leaving now (HCVM) is notorious for that, that's why they are leaving them the 1st of the year. I'm a little leery on calling back, but I definately will, I don't want to call back and be told the surgery ISNT covered
Actually, once you get the "hang" of it, you might enjoy a PCP plan. It really gives you the most options - limited only by your pocketbook. Don't be afraid to call back. Write your questions out - is the $1500 a deductible or OOP? What do I have to do before having surgery? (Usually requires pre-approval, but most doctors are set up to handle that). This way, you want get confused at all the information they are throwing at you. Good luck!
To update my situation, the supervisor from my medical insurance provider left a voicemail at my office. She contacted the providers, and they have written off the discounts, as they were supposed to do. John
Since ths is a new policy, you should double check the provisions for pre-existing conditions BEFORE you go into surgery.
