Need Health Insurance Advice

[rhirhi 35]

My husband (USC) came off his parents' health insurance and got his own at the start of this year. Premium of $167.50pp with a deductible of $2000pp. He did this in a sort of blind panic when he had to go down to the office to sort it out because the website (Health Connector) kept throwing up errors. When I married him, I was put on his health insurance. We had a lot of trouble with this, we got married in June and I didn't get put on until the end of August because we kept being told that I'd been put on there when I hadn't been. Basically it's been a huge headache since day 1.

I went to the doctor's office for the first time yesterday. All I needed was a prescription for my asthma pump, which I had run out of. I was given a full first-time patient basic checkup (blood pressure, listened to my lungs etc), but didn't need any blood tests or anything out of the ordinary. I was given a prescription for my inhaler and sent on my way. Went to pick up the prescription, discovered that we hadn't met our deductible so we had to pay out of pocket. $220 for an inhaler. I then started to panic about how much the doctor's office visit is going to cost us (any ideas of a ballpark figure?)

Both my husband and I were really foolish in thinking that the $2000 deductible that he initially had would stay the same when I was added to the insurance. I don't know why we never thought about the fact that it would be doubled with another person added to it. I know, it sounds silly now, but we never even really thought about it.

I was hoping that someone on here could give us some advice about what to do when open enrollment starts again on the 15th. What kind of plan should we be looking for? I'm fairly healthy although I have minor chronic issues (like the asthma) that will likely require at least 1 OV per year and prescriptions throughout the year. Hubby doesn't have any chronic issues. We earn a decent amount combined but we are currently saving like crazy to move out of our apartment next August, so a large monthly premium wouldn't be ideal...but then again I don't really want to fork over $220 every time I need a new inhaler. I don't see how we could ever meet our current combined deductible of $4000 (obviously unless emergency treatment was needed) but there's no way we could afford $800+ per month premiums. I feel so confused over why we've paid our premiums each month and have still had to pay a big chunk of money for basic care. Are we missing something here? We both feel really stupid at the moment

[Merrytooth 5,748]

I was given a full first-time patient basic checkup (blood pressure, listened to my lungs etc),

Did the checkup listed as yearly routine preventive care examination / Annual Physical Exam (which is free and covered by insurance)?

If not, you will get billed for it.

My Explanation of Benefits (EOB) for the yearly preventive care was around $300.

[Umka36 781]

Typically lower premiums = larger deductible and higher maximum out of pocket limits. My insurance premium is over $850, but my employer pays most of it which offers my family a lower deductible and my maximum out of pocket is what your deductible is. Do you or your spouse's employer offer medical insurance?

Obamacare as people call it may offer reasonable insurance premium rates, but people have to pay a large deductible so it's not really affordable for some/many people. Have you tried going to a clinic and just paying cash, because sometimes it can be cheaper than using the insurance? It's just a thought.

[yuna628 9,717]

I hope this will provide you with a least a little more knowledge on how this works. I asked my sister about this who has over 20+ years of experience in the medical and insurance industry. From a personal standpoint, your current insurance sounds a lot like mine, and yes, my deductible will go up if I add my fiancé to it after we're married.

Because you have an insurance with a deductible I cannot tell you how much out of pocket you will have to pay for your doctor's visits, as this is something that would be written into your policy and varies from company to company and if your doctor participates with that insurance.

If your doctor did participate with your insurance the cost is usually reduced or split between you and your insurance company. Let's say the doctor charged $100, you may only have to pay $50 of it, and the insurance may pick up the remainder. Once your deductible is met, in general you will only have to pay a standard co-pay somewhere between $20-40 (it also varies) and the insurance picks up the rest. With prescriptions it's different. My sister tells me that asthma medications can be extremely costly on the market, so $220 makes sense to her as a cost. For one thing, it is possible the drug you have is not a generic version (a cheaper version). Drugs usually operate in insurance companies on a tier system. It's likely your drug was a tier 2 or 3, which required you to pick up a higher cost. You have the option of asking your doctor to find a cheaper version that is on a list of cheaper accepted drugs covered by your insurance (which would also be noted in your policy). Some drugs are excluded from insurances entirely, and require doctors to try and prior authorize them for you (deeming them necessary for your treatment). Often staff have to fight with insurance companies over this. Of course not everyone is able to select a cheaper drug, including something so important for asthma. In this case, she suggests asking your doctor or even the pharmacy if they have any prescription savings cards available, that may help with the cost. Unfortunately, you'll find the nuances of insurance aren't very helpful. As a general rule of thumb the lower the deductible the more you have to end up paying up front for premiums. The higher or the middle of the road deductible are split between the customer and the company, with out of pocket costs higher. These types are usually designed as ''wellness'' plans only the most helpful when you need hospital care or something with big bills.

My current insurance is an old plan, that is a middle of the road deductible, with about a $200 premium, a basic co-pay, with drugs that are fairly cheap. This plan is a grandfathered in plan, which does not fall under the ACA mandate. I will have a choice to make when we marry if I add him to my plan (deductible goes up as well as the premium) or I drop it and move over to the ACA. Either way I'm not too thrilled with the prospect. Sometimes when I need a quick visit to a doctor for an antibiotic, I'll go to a clinic. That used to work out well, except now my insurance likes to consider it a ''specialist'' visit, and will charge me a higher co-pay. At least the antibiotics are cheap.

Edited November 13, 2014 by yuna628

[rhirhi 35]

Thanks all. Merrytooth, I'm not sure what they listed it under. I tried to call the doctor's billing department today to check, but I kept getting their voicemail.

Umka, I currently work as a substitute in a school so I'm not entitled to any employee benefits. My husband works for a grocery store chain, which I know provides health and dental so he's going to look into that this week. He remembers his boss telling him that it's nothing great though. I knew that you could pay up front and get a discount, but I hadn't expected to pay anything other than the co-pay yesterday. Will have to look into that next time.

Yuna, thanks for that. I've scoured our policy and it doesn't give any hint of how much the office visit would be. I know that it's $50 after the deductible is met, but we haven't met it yet. The doctor I went to is in-network and listed as my PCP on the policy. If I understand you correctly, our insurance might pay for some of the cost of the visit, even though our deductible has not been met? In terms of the inhaler, the doctor asked if I minded having the generic version and I said that it made no difference to me, though I know she was trying to match the prescription with my existing medication from the UK so she might have ended up giving me name-brand.

An expensive lesson!

Edited November 13, 2014 by rhirhi

[Nich-Nick 3,354]

I was hoping that someone on here could give us some advice about what to do when open enrollment starts again on the 15th. What kind of plan should we be looking for? I'm fairly healthy although I have minor chronic issues (like the asthma) that will likely require at least 1 OV per year and prescriptions throughout the year. Hubby doesn't have any chronic issues. We earn a decent amount combined but we are currently saving like crazy to move out of our apartment next August, so a large monthly premium wouldn't be ideal...but then again I don't really want to fork over $220 every time I need a new inhaler. I don't see how we could ever meet our current combined deductible of $4000 (obviously unless emergency treatment was needed) but there's no way we could afford $800+ per month premiums. I feel so confused over why we've paid our premiums each month and have still had to pay a big chunk of money for basic care. Are we missing something here? We both feel really stupid at the moment

Your current policy is more of a catastrophic coverage. If you had a terrible accident requiring a lot of treatment. Or if something major happened you would not believe the costs. I had to spend a week in the hospital after surgery and the hospital billed $40,000. That did not include the surgeon, anesthesiologist, or pathologist bills. If you were diagnosed with cancer, your bills could approach half a million in a year. A round of chemo can cost $10-15 thousand. One CT scan--thousands. On the positive side, your insurance has negotiated rates with those in network. That hospital may bill $40k, but has agreed in the contract to charge no more than $15k for those particular services. You are never responsible for anything over the negotiated price. And the insurance will pay the bulk of that...maybe 80% (after deductible) depending on your policy. The other thing to look at is the out-of-pocket max. There is an amount that once you reach that point, your insurance will pay 100% for the rest of the year.

So examples of choices.

Pay $200/month ($2400/year) knowing you will probably bear the costs of your one visit per year, but knowing if something godawful happens you are covered for huge expenses. And your actual rate is negotiated lower than the price tag the doctor has on his services. Drugs may have a different deductible. Mine always did that separately. So likely not $2000. Call the pharmacy and ask how much more on your deductible. They obviously have it on record and may be quicker than calling the insurance number.

Pay $800/month ($9600/year) with maybe a $250 deductible, knowing you may still pay the cost of that one office visit, but if you go two or three times, the insurance would kick in after the low deductible.

It is a guessing game or gamble really and the policies, premiums, deductibles, and out-of pocket all vary. The lowest premiums mean you may pay $2000 before you get insurance help, but at least you are taken care of for the catastrophes. That's kind of what insurance is all about. The company offering you low premiums is gambling that you are young and healthy so won't have a heart attack or cancer or an auto accident that breaks all your bones. And your high deductible means they don't really pay for a few routine office visits. And at least with insurance the high sticker price is negotiated when you stay in network.

So that's some roughed out basics that doesn't really cover the details, but maybe helps you understand a little better when looking at policies.

[rhirhi 35]

Your current policy is more of a catastrophic coverage. If you had a terrible accident requiring a lot of treatment. Or if something major happened you would not believe the costs. I had to spend a week in the hospital after surgery and the hospital billed $40,000. That did not include the surgeon, anesthesiologist, or pathologist bills. If you were diagnosed with cancer, your bills could approach half a million in a year. A round of chemo can cost $10-15 thousand. One CT scan--thousands. On the positive side, your insurance has negotiated rates with those in network. That hospital may bill $40k, but has agreed in the contract to charge no more than $15k for those particular services. You are never responsible for anything over the negotiated price. And the insurance will pay the bulk of that...maybe 80% (after deductible) depending on your policy. The other thing to look at is the out-of-pocket max. There is an amount that once you reach that point, your insurance will pay 100% for the rest of the year.

So examples of choices.

Pay $200/month ($2400/year) knowing you will probably bear the costs of your one visit per year, but knowing if something godawful happens you are covered for huge expenses. And your actual rate is negotiated lower than the price tag the doctor has on his services. Drugs may have a different deductible. Mine always did that separately. So likely not $2000. Call the pharmacy and ask how much more on your deductible. They obviously have it on record and may be quicker than calling the insurance number.

Pay $800/month ($9600/year) with maybe a $250 deductible, knowing you may still pay the cost of that one office visit, but if you go two or three times, the insurance would kick in after the low deductible.

It is a guessing game or gamble really and the policies, premiums, deductibles, and out-of pocket all vary. The lowest premiums mean you may pay $2000 before you get insurance help, but at least you are taken care of for the catastrophes. That's kind of what insurance is all about. The company offering you low premiums is gambling that you are young and healthy so won't have a heart attack or cancer or an auto accident that breaks all your bones. And your high deductible means they don't really pay for a few routine office visits. And at least with insurance the high sticker price is negotiated when you stay in network.

So that's some roughed out basics that doesn't really cover the details, but maybe helps you understand a little better when looking at policies.

Superb as always, thanks Nich-Nick. Yeah, there's not really much we can do about our current policy now, but that helps immensely when it comes to choosing a new policy for next year.