Health Insurance Calculation

[Stuwoolf 44]

Trying to get me head around US Medical Bills and calculating how much is paid.

 

The scenario:

 

Health Insurance Plan

Deductibles = 5,000 (Fig 1)

Co Insurance is 30% (Fig 2)

Max Out of Pocket is 6,000 (3)

 

 

Medical Bill is 40,000 (4)

Deductible = 5,000 (1) (paid by policyholder)

Balance = 35,000 (5)

 

Apply Co Insurance percentage of 30% (2) to 35,000 (5) = 10,500 (6)

Gross Amount to be paid is 10,500 (6) + Deductibles 5,000 (1) = 15,500 (7)

 

Apply Max Out of Pocket of 6,000 (3)

 

Net Amount to Pay is 5,000 (1) (Deductibles) + 6,000 (3) (Max Out of Pocket) = 11,000 (8)

 

Is this calculation correct?

 

I know there are other things to be considered eg prescriptions, visit to doctor etc, and I will get to them once I understand this bit.

 

Grateful for some guidance on this.

Edited October 8, 2020 by Stuwoolf

[Lucky2Lucky 2,526]

2 hours ago, Stuwoolf said:

Trying to get me head around US Medical Bills and calculating how much is paid.

 

The scenario:

 

Health Insurance Plan

Deductibles = 5,000 (Fig 1)

Co Insurance is 30% (Fig 2)

Max Out of Pocket is 6,000 (3)

 

 

Medical Bill is 40,000 (4)

Deductible = 5,000 (1) (paid by policyholder)

Balance = 35,000 (5)

 

Apply Co Insurance percentage of 30% (2) to 35,000 (5) = 10,500 (6)

Gross Amount to be paid is 10,500 (6) + Deductibles 5,000 (1) = 15,500 (7)

 

Apply Max Out of Pocket of 6,000 (3)

 

Net Amount to Pay is 5,000 (1) (Deductibles) + 6,000 (3) (Max Out of Pocket) = 11,000 (8)

 

Is this calculation correct?

 

I know there are other things to be considered eg prescriptions, visit to doctor etc, and I will get to them once I understand this bit.

 

Grateful for some guidance on this.

You almost got it.. 

Your deductible should go towards your out of pocket max. Please see bold.

((I also want to point out one possible exception. You may have in network benefits and out of network benefits. This means there are certain providers/facilities that are contracted with your insurance aka in network . As long as you use providers in network your calculations would be correct. However, if you DO have out of network benefits your deductible and out of pocket max may be different then the example you gave. For example your in network benefits may be $5,000 deductible, coinsurance 30% and out of pocket max $6,000 BUT your out of network benefits may be $8000 deductible, coinsurance 35% and $10,000 deductible... so by using out of network providers it would cost you much more over time. In addition some plans may may not  have out of network benefits and this means any bills if you go to a provider out of network the patient is responsible for 100% of charges. Hope this didn't confuse you and if it did ask questions or just ignore it and look at the bold below )

 

Medical Bill is 40,000 (4)

Deductible = 5,000 (1) (paid by policyholder)

Balance = 35,000 (5)

 

Apply Co Insurance percentage of 30% (2) to 35,000 (5) = 10,500 (6) However, since you already paid your $5,000 deductible you only have to meet $1,000 to hit your out of pocket max

Gross Amount to be paid is $5,000 Deductible plus the remaining $1,000 out of pocket

 

Apply Max Out of Pocket of 6,000 (3) TOTAL OOP

 

Net Amount to Pay is 5,000 (1) (Deductibles) + 1,000 (3) (Max Out of Pocket) = 6,000 (8)

 

Edited October 8, 2020 by Luckycuds

[Stuwoolf 44]

12 hours ago, Luckycuds said:

You almost got it.. 

Your deductible should go towards your out of pocket max. Please see bold.

((I also want to point out one possible exception. You may have in network benefits and out of network benefits. This means there are certain providers/facilities that are contracted with your insurance aka in network . As long as you use providers in network your calculations would be correct. However, if you DO have out of network benefits your deductible and out of pocket max may be different then the example you gave. For example your in network benefits may be $5,000 deductible, coinsurance 30% and out of pocket max $6,000 BUT your out of network benefits may be $8000 deductible, coinsurance 35% and $10,000 deductible... so by using out of network providers it would cost you much more over time. In addition some plans may may not  have out of network benefits and this means any bills if you go to a provider out of network the patient is responsible for 100% of charges. Hope this didn't confuse you and if it did ask questions or just ignore it and look at the bold below )

 

Medical Bill is 40,000 (4)

Deductible = 5,000 (1) (paid by policyholder)

Balance = 35,000 (5)

 

Apply Co Insurance percentage of 30% (2) to 35,000 (5) = 10,500 (6) However, since you already paid your $5,000 deductible you only have to meet $1,000 to hit your out of pocket max

Gross Amount to be paid is $5,000 Deductible plus the remaining $1,000 out of pocket

 

Apply Max Out of Pocket of 6,000 (3) TOTAL OOP

 

Net Amount to Pay is 5,000 (1) (Deductibles) + 1,000 (3) (Max Out of Pocket) = 6,000 (8)

 

Thanks for this. It helps my understanding.

 

Having looked further at health insurance, I came across the policy in the attached screen print. Grateful if someone with a bit more understanding of the system is able to explain to me what it means and what is available for the money paid.

 

Zero deductibles has been chosen as, to me, a child of the UK NHS, it seems like the best thing to do. I have never had to pay for medical services in my life and this seems like the way to proceed.

[Lucky2Lucky 2,526]

I would be hesitant for that plan and need more details. Are you just shopping around for now for when you immigrate to the US? Will you be a family (if so how many people) or one person needing insurance? How old are you? Your profile says Florida- is that where you plan on living? Also, do you currently have any health conditions that need follow up? 

Edited October 9, 2020 by Luckycuds

[Stuwoolf 44]

2 minutes ago, Luckycuds said:

I would be hesitant for that plan and need more details. Are you just shopping around for now for when you immigrate to the US? Will you be a family (if so how many people) or one person needing insurance? How old are you? Your profile says Florida- is that where you plan on living? Also, do you currently have any health conditions that need follow up? 

 

I am just shopping around right now, trying to see whats out there (there are loads!) and trying to understand what each of them offer. I am 61 years old. No health conditions. My Spouse is a USC so we may not be able to both be on the same health policy. We will look at a separate plan for my wife.

 

Thanks again for taking the time to assist me. I really do not have a clue about all this. As I said, I am a child of the UK National Health Service which is free at the point of need.

[yuna628 9,676]

10 minutes ago, Stuwoolf said:

 

I am just shopping around right now, trying to see whats out there (there are loads!) and trying to understand what each of them offer. I am 61 years old. No health conditions. My Spouse is a USC so we may not be able to both be on the same health policy. We will look at a separate plan for my wife.

 

Thanks again for taking the time to assist me. I really do not have a clue about all this. As I said, I am a child of the UK National Health Service which is free at the point of need.

Is there any particular reason why you don't think you cannot be on your spouse's insurance plan? Unless they are currently using Medicare or Medicaid, you'd certainly be eligible. If you are not joining your spouse's plan, then I would try using the ACA or purchasing a private plan once the UKC arrives. The plan you're looking at is a type of travel medical insurance which is not reflective of the coverage most have nor will it offer pre-existing ACA coverage as is required by law. If it does it will be extremely pricey or limited in nature. Keep in mind with these type of plans not every doctor, practice, or even hospital may accept it either.

[Stuwoolf 44]

14 minutes ago, yuna628 said:

Is there any particular reason why you don't think you cannot be on your spouse's insurance plan? Unless they are currently using Medicare or Medicaid, you'd certainly be eligible. If you are not joining your spouse's plan, then I would try using the ACA or purchasing a private plan once the UKC arrives. The plan you're looking at is a type of travel medical insurance which is not reflective of the coverage most have nor will it offer pre-existing ACA coverage as is required by law. If it does it will be extremely pricey or limited in nature. Keep in mind with these type of plans not every doctor, practice, or even hospital may accept it either.

I assumed as I am the immigrant and my wife is USC a single healthcare policy may not cover both?

 

You mentioned "a type of travel  medical insurance". That was my thought too. I think I need to revisit and look at what else is available.

 

What is ACA?

 

Thanks for your help.🙂

 

 

Edited October 9, 2020 by Stuwoolf

[Boiler 45,486]

It is MUCH easier to let you wife run with this as she will be familiar with the system.

 

The normal option for a spouse immigrating would be to be added to the spouses US cover which for most is provided by their Employer.

 

Patriot is a limited cover, so anything serious and you would blow through the cover provided and have to pay the balance and not ACA compliant.

 

ACA = Affordable Care Act.

 

At61 you also need ot be thinking of Medicare and qualifying for that.

[Lucky2Lucky 2,526]

1 hour ago, Stuwoolf said:

I assumed as I am the immigrant and my wife is USC a single healthcare policy may not cover both?

 

You mentioned "a type of travel  medical insurance". That was my thought too. I think I need to revisit and look at what else is available.

 

What is ACA?

 

Thanks for your help.🙂

 

 

If your wife has insurance through her job you could be added to her plan- that is usually the best (cheapest) and easiest. The next place I would suggest to search is https://www.healthcare.gov you will qualify under a life qualifying event/special enrollment period once you immigrate to the US. (Otherwise If you were already in the US you would only be able to enroll or make changes during the open enrollment period Nov 1- Dec 15.) The plans on that website are part of the Affordable Care Act (ACA / Obamacare) I highly suggest getting on wife’s plan or purchasing through healthcare.gov- only those options. Start browsing that site and come back with questions. You would not be able to qualify for Medicaid or Medicare as a new immigrant however. 

[yuna628 9,676]

13 hours ago, Stuwoolf said:

I assumed as I am the immigrant and my wife is USC a single healthcare policy may not cover both?

 

You mentioned "a type of travel  medical insurance". That was my thought too. I think I need to revisit and look at what else is available.

 

What is ACA?

 

Thanks for your help.🙂

 

 

The ACA is the affordable care act, otherwise known as Obamacare. It created an exchange... kind of like a glorified search engine for health care plans which may be offered at reduced cost (no guarantee of this) to some. They typically run on tiers - silver, gold, platinum. The more you pay in premiums, typically the better the coverage and less out of pocket costs. The less you pay in premiums, the higher the out of pocket cost. The ACA also has strict requirements such as coverage for everyone and pre-existing conditions are included. There are rules however about when you can sign up and who is eligible. Some states have their own exchange in place of the federal exchange. Immigrants are certainly eligible to use plans of their spouses, provided it is not Medicare or Medicaid.

 

Most people get insurance that way, if they are not included on the spouse's plan. When my husband came to the US I added him to my private ACA compliant plan, and then when he started working he moved us both over to his employer plan. His employer pays a portion and so does he. He chose a plan with a higher premium, but it ultimately means that we have little to pay out. A surgery for me cost over $40k, and we only owed a few hundred.

 

I'd encourage going over this info with the USC spouse. They are really going to be the one handling things like that.

[Wuozopo 4,293]

The OP’s profile says DCF which means the USC wife is not currently employed or residing in the US. They will both be shopping for policies or a joint family policy. 
 

Shopping https://www.healthcare.gov is a place to start and find companies offering coverage in your area. If you find some companies that Interest you, then check direct offerings and additional plans offered on the company’s website.  Signing up on healthcare.gov is mostly beneficial if you are poor.  

 

Edited October 9, 2020 by Wuozopo

[Stuwoolf 44]

10 minutes ago, Wuozopo said:

The OP’s profile says DCF which means the USC wife is not currently employed or residing in the US. They will both be shopping for policies or a joint family policy. 
 

Shopping https://www.healthcare.gov is a place to start and find companies offering coverage in your area. If you find some companies that Interest you, then check direct offerings and additional plans offered on the company’s website.  Signing up on healthcare.gov is mostly beneficial if you are poor.  

 

Good advice and most welcomed.🙂 Thank you

 

I guess its things like this that, although from afar we think we know and understand, its only when looking more closely it becomes apparent how complex it all is. Especially so when health insurance is something never before required.

Edited October 9, 2020 by Stuwoolf

[Boiler 45,486]

Quite common for someone doing DCF to have the USC go back first to get a job, set up things, get healthcare.

[Wuozopo 4,293]

13 minutes ago, Stuwoolf said:

Good advice and most welcomed.🙂 Thank you

Obamacare offers help with premiums if your family income for 2021 from all sources...wages, interest, dividends, pensions, IRA withdrawals, capital gains...will be less than something like $67,000. Some states have offerings as well. And there is the chance that Obamacare (Affordable Care Act, ACA) will be thrown out if the president is re-elected or so is hinted. It’s hard to give you exact info, so keep wading through it.