Explain how health insurance deductible works

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Eurookat
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Explain how health insurance deductible works

Post by Eurookat » Mon Mar 06, 2017 10:29 pm

I'm looking at health insurance info from a job offer I received. I didn't realize how good my current company's plan is compared to what's out there. At first I was shocked that the new job requires me to only pay half of what i'm paying now per month. Now I know why.

So here's what i know. My current plan has $0 deductible. For the most part, everything we need (kids immunization and routine preventive maintenance) are covered 100%. The most I've paid was $1000 to have our kids delivered. So looking at the new plan I'm seeing a deductible amount.

For in-network providers $1,500 person / $3,000 family;
For out-of-network providers $3,000 person / $6,000 family.
Does not apply to in-network preventive care, in-network
office visits, emergency room visits, urgent care facility
visits. Co-payments don't count toward the deductible.

See the chart starting on page 2 for how much you
pay for covered services after you meet the deductible.


So now page 2 shows (I'm only going to show a few examples we actually need).

Primary care visit to treat an injury or illness -$20 co-pay/visit
Diagnostic test (x-ray, blood work) - No charge


With the example above, let's say the doctor charges us $145 for a well-visit for my son. With our current plan, I don't have to pay anything. When he's sick and has to see his doctor, I pay a co-pay of $20 or so. With the new plan, does this mean I'm on the hook for $145?

The same goes for bloodwork. I get routine bloodwork every 6 months. I'm covered 100%. If my EOB shows a total of $500, does that mean I pay the $500?!

I really need to sit down and compare the cost. I don't want to switch jobs and end up with crappy insurance. However, I realize many employers are struggling to offer "good" coverage at a decent price. With the "savings" I have from not having to pay too much each month, I would probably put that towards savings and the cost of healthcare throughout the year. So it's not really a savings.

UPDATED WITH SCREENSHOT
http://imgur.com/a/r1ZIJ
Last edited by Eurookat on Mon Mar 06, 2017 10:59 pm, edited 1 time in total.

123
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Re: Explain how health insurance deductible works

Post by 123 » Mon Mar 06, 2017 10:40 pm

The only way to meet the deductible is to pay expenses out of pocket. Accordingly, you would pay $145 for the visit for your son and that $145 would be applied to the deductible. Until you meet the deductible your "co-pay" is the complete (negotiated) charge. Generally preventative care is covered by most plans and there is no deductible connected with it.

YMMV
Last edited by 123 on Mon Mar 06, 2017 10:44 pm, edited 1 time in total.
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Incendiary
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Re: Explain how health insurance deductible works

Post by Incendiary » Mon Mar 06, 2017 10:42 pm

It looks like lab work is included. Also, it says in network office visits are covered, so the $145 you cite seems like it would be covered. I'm not sure what is not covered. Surgeries?

theplayer11
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Re: Explain how health insurance deductible works

Post by theplayer11 » Mon Mar 06, 2017 10:46 pm

I read it as deductible does not apply for preventive care*(as is the AHC law)

$3000 family deductible does not make a "crappy" plan..Mine is $11k

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Kosmo
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Re: Explain how health insurance deductible works

Post by Kosmo » Mon Mar 06, 2017 10:47 pm

You will pay the negotiated rate (what your insurance plan has agreed to pay for whatever particular billing/procedure code) until you hit the deductible. Once you hit that number, then you'll pay according to the guidelines on page 2. The blood work may be a list price of $500, but the insurance negotiated rate could be $150. You'll pay that. The way to find out what things will cost is to get the billing code for the procedure and then ask the insurance company how much it will cost you.

Somewhere in the plan documents will be a max out of pocket number. That is the most you'll be on the hook for in any given calendar year (plus the premium).

Eurookat
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Re: Explain how health insurance deductible works

Post by Eurookat » Mon Mar 06, 2017 10:48 pm

Incendiary wrote:It looks like lab work is included. Also, it says in network office visits are covered, so the $145 you cite seems like it would be covered. I'm not sure what is not covered. Surgeries?


I compared this particular plan to the one we have now. It looks like it matches line by line (some costs are a little more like copays) but otherwise the services we need or have needed appear to be covered. I was confused because of this wording ... "see the chart starting on page 2 for how much you
pay for covered services after you meet the deductible."

It sounds to me that the services would be covered ONLY after I pay up to my deductible?

Eurookat
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Re: Explain how health insurance deductible works

Post by Eurookat » Mon Mar 06, 2017 10:50 pm

theplayer11 wrote:I read it as deductible does not apply for preventive care*(as is the AHC law)

$3000 family deductible does not make a "crappy" plan..Mine is $11k


This is what I need to confirm. I thought preventive care is covered under the AHC law like you said.

Agreed, $3k isn't bad compare to what others are paying. I guess I'm spoiled w/ what we have now. I dont want to say no to this job because of this. Who knows, my current employer may get rid of our existing plan come open enrollment.

jbuzolich
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Re: Explain how health insurance deductible works

Post by jbuzolich » Mon Mar 06, 2017 10:51 pm

There should be a lot more details on coverage but from what is posted the well-child visit would be full cost, meaning paid at negotiated rate rather than only a copay, and tracked towards the yearly deductible. That would be something like a scheduled visit for 2 year check up and immunizations or perhaps a school clearance. Sick kid though would only be the copay which does not apply towards deductible. No cap on the copays so if you there for fifty visits you pay each time.

Eurookat
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Re: Explain how health insurance deductible works

Post by Eurookat » Mon Mar 06, 2017 10:56 pm

Kosmo wrote:You will pay the negotiated rate (what your insurance plan has agreed to pay for whatever particular billing/procedure code) until you hit the deductible. Once you hit that number, then you'll pay according to the guidelines on page 2. The blood work may be a list price of $500, but the insurance negotiated rate could be $150. You'll pay that. The way to find out what things will cost is to get the billing code for the procedure and then ask the insurance company how much it will cost you.

Somewhere in the plan documents will be a max out of pocket number. That is the most you'll be on the hook for in any given calendar year (plus the premium).


Out-of-pocket is $8k for family. So the "No Charge" listed is only after I meet the $3k deductible?

delamer
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Re: Explain how health insurance deductible works

Post by delamer » Mon Mar 06, 2017 10:57 pm

Incendiary wrote:It looks like lab work is included. Also, it says in network office visits are covered, so the $145 you cite seems like it would be covered. I'm not sure what is not covered. Surgeries?


This looks right to me.

Does the new company offer a FSA or HSA to let you set aside pretax money to cover the deductible and co-pay? What is the maximum out-of-pocket in both plans? How much is the premium difference for you?

Whether you pay upfront through your share of the premium or at the time of service, you are going to pay somehow. I'd pay more attention to the maximums. Insurance's main purpose should be to protect against catastrophic expenses.

The preventive care is required to be no cost by the ACA, is my understanding.
Last edited by delamer on Mon Mar 06, 2017 11:06 pm, edited 1 time in total.

Eurookat
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Re: Explain how health insurance deductible works

Post by Eurookat » Mon Mar 06, 2017 10:57 pm

jbuzolich wrote:Sick kid though would only be the copay which does not apply towards deductible. No cap on the copays so if you there for fifty visits you pay each time.


Is it just co-pay or the cost of the visit + copay (assuming I havent met the deductible yet)?

Eurookat
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Re: Explain how health insurance deductible works

Post by Eurookat » Mon Mar 06, 2017 11:02 pm

delamer wrote:
Incendiary wrote:It looks like lab work is included. Also, it says in network office visits are covered, so the $145 you cite seems like it would be covered. I'm not sure what is not covered. Surgeries?


This looks right to me.

Does the new company offer a FSA or HSA to let you set aside pretax money to cover the deductible and co-pay? What is the maximum out-of-pocket in both plans? How much is the premium difference for you?

Whether you pay upfront through your share of the premium or at the time of service, you are going to pay somehow. I'd pay more attention to the maximums.


Yes to FSA. Yeah i was excited when I saw how much cheaper health insurance is. Then I ran the numbers and now I'm thinking [OT comment removed by moderator prudent] I really didn't get a raise because I'll end up paying just as much if not more with health insurance over the course of a year.

Loandapper
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Re: Explain how health insurance deductible works

Post by Loandapper » Mon Mar 06, 2017 11:04 pm

OP: FWIW, this is actually a decent health insurance plan.

Not my plan, but some companies have higher deductibles - like $5,000 for a family - and they only cover 80%. Plus, they don't cover primary care visits.

Got poison ivy? You're paying ($189) to see your primary care physician or visit urgent care. Prescriptions? Not covered until you hit $5,000 out of pocket. Fall off a ladder? Car accident? Cancer? You're paying $5,000 plus 20% of all other costs.

Eurookat
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Re: Explain how health insurance deductible works

Post by Eurookat » Mon Mar 06, 2017 11:06 pm

Loandapper wrote:OP: FWIW, this is actually a decent health insurance plan.

Not my plan, but some companies have higher deductibles - like $5,000 for a family - and they only cover 80%. Plus, they don't cover primary care visits.

Got poison ivy? You're paying ($189) to see your primary care physician or visit urgent care. Prescriptions? Not covered until you hit $5,000 out of pocket. Fall off a ladder? Car accident? Cancer? You're paying $5,000 plus 20% of all other costs.


Agreed, as I've mentioned, comparing it to what I have now is what's opening my eyes to the cost of healthcare. I'm really hoping the preventive stuff is covered 100%. I won't plan for urgent care or hospital stays. Those could happen and if they do we'll deal with it if/when it happens. I want to make sure it makes sense for our family since I have two little kids.

HIinvestor
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Re: Explain how health insurance deductible works

Post by HIinvestor » Mon Mar 06, 2017 11:13 pm

OP, your HR person should be able to give you a full copy of your policy, so you can read it to find out which things are exempt from having to meet the deductible. Under the ACA, things such as well child checks ups, shots, and other important preventative care are covered under insurance and you have NO copay and do not have to meet any deductible, but the full copy of the policy will spell all of that out so you don't have surprises.

I agree that you would end up paying whatever the insurer has negotiated as the rate for your visits and also lab work for things that add up to your deductible. Some offices will give you a discount if you pay cash when you have your visit instead of them having to bill you. All the amounts you pay have to equal the deductible before your insurer will pay for anything other than those specially stated items such as preventative care. If you want to find out how much you will need to pay out of pocket, you can ask the provider and/or your insurer.

I have read of much worse policies than the one you have. So far, we have never had a policy with a deductible except for a few months when S was aged off of our policy and before he aged back in due to the ACA, so I don't have much personal experience with deductibles. We have had copays all my life and out-of-pocket maximum payments for the year, which we have hit some years individually and as a family.

Eurookat
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Re: Explain how health insurance deductible works

Post by Eurookat » Mon Mar 06, 2017 11:23 pm

HIinvestor wrote:OP, your HR person should be able to give you a full copy of your policy, so you can read it to find out which things are exempt from having to meet the deductible. Under the ACA, things such as well child checks ups, shots, and other important preventative care are covered under insurance and you have NO copay and do not have to meet any deductible, but the full copy of the policy will spell all of that out so you don't have surprises.

I agree that you would end up paying whatever the insurer has negotiated as the rate for your visits and also lab work for things that add up to your deductible. Some offices will give you a discount if you pay cash when you have your visit instead of them having to bill you. All the amounts you pay have to equal the deductible before your insurer will pay for anything other than those specially stated items such as preventative care. If you want to find out how much you will need to pay out of pocket, you can ask the provider and/or your insurer.


Yep I have it. I took a screenshot of the first two pages (original post). I re-read the block and it looks like preventive care is covered at 100%. I originally thought it said the cost paid towards it wouldn't apply towards the deductible.

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Kosmo
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Re: Explain how health insurance deductible works

Post by Kosmo » Mon Mar 06, 2017 11:30 pm

The screen shots are slightly confusing. It doesn't say what happens after you hit the deductible. Unless that's when it switches over from paying the negotiated rate to paying co-pays (I've never seen a plan like that, but that doesn't mean they don't exist). Usually you pay the co-pay when you see the doctor and pay for other services (tests, ER, etc.) at the negotiated rate. After you hit the deductible then increased benefits kick in, something like you pay 10% of the negotiated rate.

Preventive care is covered 100% as part of ACA. You don't pay for those services. No charge for testing is a good deal.

It doesn't look like this is a HDHP, so no HSA.

JGoneRiding
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Re: Explain how health insurance deductible works

Post by JGoneRiding » Tue Mar 07, 2017 12:31 am

Eurookat wrote:
HIinvestor wrote:OP, your HR person should be able to give you a full copy of your policy, so you can read it to find out which things are exempt from having to meet the deductible. Under the ACA, things such as well child checks ups, shots, and other important preventative care are covered under insurance and you have NO copay and do not have to meet any deductible, but the full copy of the policy will spell all of that out so you don't have surprises.

I agree that you would end up paying whatever the insurer has negotiated as the rate for your visits and also lab work for things that add up to your deductible. Some offices will give you a discount if you pay cash when you have your visit instead of them having to bill you. All the amounts you pay have to equal the deductible before your insurer will pay for anything other than those specially stated items such as preventative care. If you want to find out how much you will need to pay out of pocket, you can ask the provider and/or your insurer.


Yep I have it. I took a screenshot of the first two pages (original post). I re-read the block and it looks like preventive care is covered at 100%. I originally thought it said the cost paid towards it wouldn't apply towards the deductible.


Sometimes what they mean by your last line is: non yearly checkup (something besides your wellness) is a 20 co pay for a doctors visit with primary care and that that 20 (all you pay to see the doctor but labs are separate ) doesn't go towards your deductible amount. But "everyone "with aca complaint insurance should get a "free" yearly checkup/physical

Incendiary
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Re: Explain how health insurance deductible works

Post by Incendiary » Tue Mar 07, 2017 12:35 am

Post it verbatim and I'll try to help you decipher it.

JustMe
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Re: Explain how health insurance deductible works

Post by JustMe » Tue Mar 07, 2017 12:43 am

Many of the answers that have been provided so far are completely wrong, even before looking at the screenshot you added later. There is a toll-free phone number at the top of one of the pages you posted. I suggest you call it and talk through some scenarios rather than relying on the mostly incorrect information that has been posted here.

But to add to your confusion, I've attempted to answer some of your questions. All my answers assume you are seeing in-network providers.
Eurookat wrote:
For in-network providers $1,500 person / $3,000 family;
For out-of-network providers $3,000 person / $6,000 family.
Does not apply to in-network preventive care, in-network
office visits, emergency room visits, urgent care facility
visits. Co-payments don't count toward the deductible.

When it says the deductible does not apply, it means for those listed services (primary or specialist doctor's office visits and even urgent care or ER visits) you will pay only the specified copay regardless of whether you have hit the deductible. When it says co-payments don't count toward the deductible it means that if you see the doctor and pay a $20 copay, then later have a hospital admission or outpatient surgery you will pay the full $1,500 deductible rather than $1,500-$20=$1480.
Eurookat wrote:With the example above, let's say the doctor charges us $145 for a well-visit for my son. With our current plan, I don't have to pay anything. When he's sick and has to see his doctor, I pay a co-pay of $20 or so. With the new plan, does this mean I'm on the hook for $145?

If your son sees a primary care doctor you will pay either $0 for a preventative care visit or $20 for a sick visit. Since this service is one of the listed items to which the deductible does not apply, the $145 is not relevant to you.
Eurookat wrote:The same goes for bloodwork. I get routine bloodwork every 6 months. I'm covered 100%. If my EOB shows a total of $500, does that mean I pay the $500?!

It looks like you will be covered 100% under the new plan as well. It may depend on the nature of the tests and how they are billed, but based on your description of "routine bloodwork" these should fall under screening or diagnostic test, both of which show as "no charge" on the image you posted.
Eurookat wrote:UPDATED WITH SCREENSHOT
http://imgur.com/a/r1ZIJ

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