Anyone got any experience with health insurance?

[Adam&Allison 128]

So I have a K1 interview on the 20th January 2017, so as a result I have been looking into health insurance options as my fiance is a college student who is currently covered under her parents insurance.

Buying my own insurance is frankly not a problem, and I'd actually rather do it so I can tailor it to how I like. I've been looking at Independence Blue Cross (I'm in PA) and have been quoted at $475 per month for gold coverage. it SEEMS ok, but I'm a little confused on some things (being from the UK, I've never had to look at it this in depth before);

1) Brand vs Generic medication. Is there any difference in effectiveness between these? It seems like the brand medications cost an awful lot more than generic, but all the FDA research points to generic being just as effective. Are there any medications that are only available as a brand vs generic?

2) The plan I got quoted for was 'Personal Choice PPO Gold' - meaning that I don't need a referral to see a specialist. I assume this means if I have, for instance lets say, a back problem - I can go directly to a back specialist? This is not a deal breaker for me as referrals are required in the UK anyways, so this would be a more 'nice to have'

3) My deductible is set at $0, as I would rather pay a higher monthly premium and less when needed, does this mean if I visit my primary care physician I'll have no charge (or a small charge, I believe copay?)

4) What is 'Out of pocket maximum'? this is referred to quite alot on the brochure I have, but I can't seem to find anywhere where it clarifies?

5) There is a column that simply says 'Emergency Room' with $350 next to it - I assume this is a charge for going to the ER?

6) I'm a diagnosed asthmatic, mild, but I do require repeat prescriptions for inhalers every month - I assume this would fall under the generic medication category (which my quoted plan says is $15 per 1-30 days)

Sorry for the abundance of questions! It's all very mind boggling! As to some more insight as to my current health status, I'm 25 years old, have asthma, but otherwise no other health problems.

Thanks!

[TBoneTX 45,289]

Thread is moved from Off Topic to the "Moving to the US" forum.

[Suss&Camm 2,213]

I'm not the usc but I'm a medicinal chemist so I can answer your first question. There is no difference in brand and generics. Generics are simply copies that pop up after the original drug patent has run out. A pharma company only has so many years to earn back invested money and cash in on their discovered and developed drugs before a patent runs out.

People are however many times very rigid in their consumer behaviors and many times stick with the brand simply cause it's what they know, even though it costs more. The only time you would find a generic and no brand name would be if the original patent holder stopped it's production.

The rest of your questions I'm also very interested in the answers to!

[Adam&Allison 128]

I'm not the usc but I'm a medicinal chemist so I can answer your first question. There is no difference in brand and generics. Generics are simply copies that pop up after the original drug patent has run out. A pharma company only has so many years to earn back invested money and cash in on their discovered and developed drugs before a patent runs out.

People are however many times very rigid in their consumer behaviors and many times stick with the brand simply cause it's what they know, even though it costs more. The only time you would find a generic and no brand name would be if the original patent holder stopped it's production.

The rest of your questions I'm also very interested in the answers to!

I assumed this was the case. I assume also that there's really not too much that is covered by a patent anymore due to medical advancements over the last half century, but I could be wrong on that!

[Russ&Caro 1,549]

My post here is mainly just to keep your thread alive in the hopes of real health insurance experts participate and answer your questions accurately. However, as a health insurance consumer and one who has done some research and has asked many of the same questions, I'll give you my take.

First, I think it's generally accepted wisdom that young, reasonably healthy people should shop for low premiums policies, silver or even bronze class. The thinking goes that it's a low probability that you'll have to rely on your insurance in any given year so why pay extra on a monthly basis for things you probably won't need or use - such as "0" deductibles (which I'd never heard of), low out-of-pocket maximums, or bypassing referrals to see a specialist. Those first two items definitely increase your premium, and I'm pretty sure the 3rd one does too.

Note, I said "any given year" because you can change from year to year as your health conditions change, or for any reason for that matter.

Second, it looks like your one health vulnerability, asthma, is already under control with medication. Your drug benefit covers this and there's usually no advantage going gold on this as drug benefits usually are the same or very similar across the general policy range.

Buying health insurance really forces a person to calibrate their risk aversion. If you are very risk averse then you're going to want the zero deductible, high premiums policy. There's nothing wrong with being very risk averse. But this is something you should capture and analyze down the road. At the end of the year, add up your total health costs and then balance it against $475 * 12 months. Then use that information in making decisions next year.

My own direct answers to your questions (these answers could be inaccurate):

1) As a former patent examiner, I agree with the response by the chemist. The patents run out and the generic producers jump in with identical products.

2) Correct on the referrals. But as I said above, I believe this comes with a higher cost. Sounds like you understand the pros and cons of requiring a referring doctor.

3) The zero deductible may still require a copay, depends on the policy. Some policies have 0 deductibles / 0 copays on most preventative visits to your primary care physician. This is part of the reason why requiring a primary care physican as gatekeeper isn't quite an onerous as it sometimes seems.

4) Out of pocket maximum applies to all health care costs charged to you before the insurance company starts picking up 100% of the costs. Many policies are constructed where you pay for 20% of the charges for services and the insurance pays for 80%. So once all those 20% charges + copays add up to the maximum, then you're off the hook for any further charges. This usually applies to serious health issues that require hospital stays and/or serious rehabilitation services, etc.

5) The $350 charge is a flat fee that you will incur no matter what if you go to the ER. All flat fees and associated services should be listed in the policy. The flat fees + the 20% + co-pays all contribute to you reaching the out of pocket maximum.

6) Asthma already answered.

Good luck!

EDIT: Fixed an inaccuracy

Edited November 29, 2016 by Russ&Caro

[yuna628 9,676]

So I have a K1 interview on the 20th January 2017, so as a result I have been looking into health insurance options as my fiance is a college student who is currently covered under her parents insurance.

Buying my own insurance is frankly not a problem, and I'd actually rather do it so I can tailor it to how I like. I've been looking at Independence Blue Cross (I'm in PA) and have been quoted at $475 per month for gold coverage. it SEEMS ok, but I'm a little confused on some things (being from the UK, I've never had to look at it this in depth before);

1) Brand vs Generic medication. Is there any difference in effectiveness between these? It seems like the brand medications cost an awful lot more than generic, but all the FDA research points to generic being just as effective. Are there any medications that are only available as a brand vs generic?

2) The plan I got quoted for was 'Personal Choice PPO Gold' - meaning that I don't need a referral to see a specialist. I assume this means if I have, for instance lets say, a back problem - I can go directly to a back specialist? This is not a deal breaker for me as referrals are required in the UK anyways, so this would be a more 'nice to have'

3) My deductible is set at $0, as I would rather pay a higher monthly premium and less when needed, does this mean if I visit my primary care physician I'll have no charge (or a small charge, I believe copay?)

4) What is 'Out of pocket maximum'? this is referred to quite alot on the brochure I have, but I can't seem to find anywhere where it clarifies?

5) There is a column that simply says 'Emergency Room' with $350 next to it - I assume this is a charge for going to the ER?

6) I'm a diagnosed asthmatic, mild, but I do require repeat prescriptions for inhalers every month - I assume this would fall under the generic medication category (which my quoted plan says is $15 per 1-30 days)

Sorry for the abundance of questions! It's all very mind boggling! As to some more insight as to my current health status, I'm 25 years old, have asthma, but otherwise no other health problems.

Thanks!

Sounds pretty good for that price.

1) Brand vs Generic. Generic drugs are going to be more affordable. Plans generally have drug tiers 1-3. Each tier will have a different cost all the way up to the most expensive and often times lifesaving which require paperwork and pre-authorization. There are some times where a generic drug won't be the best choice. For instance, if the patient has a reaction to a generic vs a brand (and vice versa) or if the doctor believes the brand works better (which can sometimes happen regarding medications for hormone treatment). Personally know this as my sister requires a brand name drug and did not respond well to a generic formula when it was tried. For this particular medication her specialists believes brand name is the best option. The average person is going to find generic drugs to be just fine for them.

2) If the plan states you don't need a referral, then yes you can go see whatever doctor you want so long as the following conditions are met: they participate with your insurance and they are a doctor within your network (network being a group of doctors in the state your insurance participates with). If you go out of network be prepared to pay a big bill. Keep in mind this can actually happen during hospital visit. The hospital may participate, but for a variety of reasons various doctors or services rendered may be given by individuals who don't. You won't really know it at the time either until a bill comes.

3/4) Let's say you need to go to an urgent care clinic to see a doctor for some sort of flu. A copay is a small flat fee for the service given that day for medication and being examined. Behind the scenes, the doctor will bill the insurance company for the rest of the cost for their services. They will not usually receive the amount they ask for in return either! Times when you would not be paying a copay is if your insurance gives you an allowance to go have 'checkups' a few times a year, these are generally freebies. Now the deductible question and the out of pocket max question go hand in hand as follows: A deductible is an amount you would pay every year for any medical services before the insurance will pick up the tab. So if you have something like $2,000 deductible, you must pay that first $2,000 before it's cost free to you for that year (your out of pocket maximum). Premiums and copays typically will not count toward this deductible.

https://www.healthmarkets.com/content/health-insurance-with-no-deductible-and-no-copay

5) The charge for $350 sounds like that will be your ER copay. No doubt you may also have copays of that sort of price for MRIs and Xrays as well.

Blue Cross is generally pretty decent health insurance company. We have it ourselves, though you are fortunate yours is significantly cheaper in cost. They are gouging us currently and dropped our coverage entirely. Since you have asthma I'd absolutely make sure you have health coverage, find a doctor, and discuss the medication you are currently in need of for a seamless transition.

Edited November 29, 2016 by yuna628

[Ontarkie 14,223]

Generics are great and most pharmacies will switch to generics.

Now for your asthma I can tell you to brace yourself for those prices. They no longer offer generic on the rescue inhaler and the steroids are still brand name. Depending on your insurance plan you pick they will also try to say you need to start and fail on the lower steroid before they will cover the better ones. If you can bring as many inhalers with you as you can. It will help till you get in to a doctor and figure out your insurance and what they will pay for.

Before moving I had the normal Ventolin inhaler and flovent. I moved here and the doctors refuse to give me flovent.

I was given 3 months of Symbicort by the doctor (samples). Then I've been on pulmicort failed it because the insurance refused to pay for symbicort. Then switched back to Symbicort then on to Breo it was supposed to be better then Symbicort but for me it caused flair ups when it wears off. Now I'm on Asmanex and it's about the same as pulmicort and pretty useless. I haven't had any major attacks but it's very sensitive and I wheeze daily.

I'm allergic to everything and that is not an exaggeration and my doctor keeps trying to tell me my inhaler should last 6 months. That will never happen unless I get back on Symbicort. I don't want Symbicort because the increase of asthma related deaths. It's a drug that Canadian doctors do not like to give out lightly. They prefer the flovent that I did well on but seems the doctors don't