Explain Insurance To Me-I'm So Lost

noffgurl · November 2014

So today begins open enrollment for H's company. I am floored by the different options- I don't know what half of them mean or how they work. All I do know is when we had insurance previously we payed a lot for a high deductible plan (the cheapest option available). It didn't cover anything because we never met the deductible and so now we have a lot of medical bills from I thought pretty routine stuff that we are struggling with. So, I don't know what I'm looking at or doing.

noffgurl · November 2014

And what the heck are FSA's and HMO's and PPO's and all the other lingo????

KatieCutie05 · November 2014

HSA - An IRS run health savings account that you contribute to pretax and then you can use that for all qualified medical expenses - it carries over each year and once you reach a certain balance it doubles as an investment so you can earn money on it. Usually only available with High Deductible insurance plans (although not all) Some companies don't offer them... some give you a certain amount in them - it varies. You can adjust your contribution as much as you want throughout the year - up to a certain amt.

FSA - A Flexible spending Account is an account used strictly for that years medical expenses - you choose a preset amount at open enrollment and cannot be changed after that. Its also put in pretax. But if you don't use it by the end of the year - you lose it.. these are available with any health plan you choose generally.

PPO vs HMO i'm not entirely sure but PPO's generally have a deductible and then once the deductible is hit - you pay a certain percentage of all your expenses. While HMO's have a set copay for doctors visits etc.

Xstatic3333 · November 2014

Can you tell us about what some of the options are?

I know that many young, healthy couples find a high deductible plan to be the cheapest way to go, but the realm of prices really varies by state and job. I would not chose a high deductible plan, however, if you'll be expanding your family within the next year. Usually, we do not chose a high deductible plan. We like the predictability of paying monthly instead of having to raid our e-fund in an emergency. We do, however, save money by chosing a limited network plan. If you're doing this, check the plan's website or call any doctors that you don't want to part with to make sure that they are in the new plan's network.

I know others around here are more knowledgeable than me about this stuff, but that's my thought process

cupcait927 · November 2014

KatieCutie05 said:

HSA - An IRS run health savings account that you contribute to pretax and then you can use that for all qualified medical expenses - it carries over each year and once you reach a certain balance it doubles as an investment so you can earn money on it. Usually only available with High Deductible insurance plans (although not all) Some companies don't offer them... some give you a certain amount in them - it varies. You can adjust your contribution as much as you want throughout the year - up to a certain amt.

FSA - A Flexible spending Account is an account used strictly for that years medical expenses - you choose a preset amount at open enrollment and cannot be changed after that. Its also put in pretax. But if you don't use it by the end of the year - you lose it.. these are available with any health plan you choose generally.

PPO vs HMO i'm not entirely sure but PPO's generally have a deductible and then once the deductible is hit - you pay a certain percentage of all your expenses. While HMO's have a set copay for doctors visits etc.

The bolded isn't really correct. PPO and HMO are different types of coverage options and networks available. PPO stands for Preferred Provider Organizations. This means that there are doctors that participate with your insurance carrier and using those doctors will get you the best rate. However, PPOs will also cover you if you choose to use an out of network doctor, but at a lesser rate. You're still getting insurance coverage, but the provider can balance bill you for whatever insurance doesn't cover. HMOs are much more selective, no out of network coverage, and the range of services can be limited. It doesn't really have anything to do with high deductibles or copays. PPOs can be copay, hybrid or HDHP. HMOs just tend to be copay plans.

FSA are flexible spending accounts. They can be used on anything medical, dental or vision. You can google eligible FSA items online. It does not rollover and you lose whatever you don't spend by the end of the year. Just be careful - if you have an HDHP plan, you cannot use your FSA on medical expenses, only dental and vision. FSAs are best if you have planned expenses throughout the year, such as monthly prescriptions, glasses or contacts, scheduleded surgery or braces for kids. All of the money in an FSA is available day one of the new plan year, even if you haven't made any contributions into the account yet.

HSAs are great. If your H's employer offers one and you have an HDHP plan, definitely contribute into an HSA. HSAs are individual bank accounts that you own. If your H leaves his job, you can take your HSA account with you. There are guidelines on what you can contribute (easy to google and you should've gotten that info with the OE stuff) and can be used in conjunctions with HDHP plans (most are eligible, some are not). You cannot contribute to an HSA if you are in a copay plan, but if you have HSA funds from a previous HDHP plan year, you can use that money on copays, etc. You can also use HSA funds for dental and vision as well.

It's not correct to say that your HDHP plan did not cover anything. While your out of pocket cost is higher on an HDHP plan, meaning you may pay $80 at the doctor instead of a $25 copay, you are still paying a negotiated amount decided upon by the insurance carrier. Without insurance, your doctor could charge you much, much more. The are limited as to what they can bill you based on your insurance. If you do decide to choose another HDHP plan over a copay plan, think about putting the difference between the per pay deductions of both plans into an HSA, so that you can start to build the account up.

*I work for an insurance broker so I work with this stuff every day.

noffgurl · November 2014

Background on our situation: We are trying to pay down a lot of stupid debt and reduce our expenses and save up. I would love to TTC within a year or two, however I know it will be expensive because we will both have to have "help".

I will try to give a summary of the options I see:
Medical: Value Plan-

Lowest cost per paycheck of all Swift medical plan options.
In-network preventive care is covered at 100%.
You'll pay a set $45 copay for in-network primary care physician office visits and urgent care clinics.
Includes the Buy-Down prescription drug plan with no prescription deductible.
Deductible amounts:
- In-network: $2,500 per individual; $7,500 per family
- Out-of-network: $5,000 per individual; $15,000 per family
After you meet your deductible and any applicable copay amounts, the plan will pay 50% of the cost for most in-network services (including specialists) and 30% for most out-of-network services. You will pay the difference (coinsurance).

Out-of-pocket maximum for Value plan:

In-network: $6,250 per individual; $12,500 per family
Out-of-network: $12,500 per individual; $25,000 per family

Buy Down-

You can use any provider, but you'll pay a lot less when you use in-network providers.
Preventive care is covered 100% (in-network).
You pay a $25 copay for in-network primary care physician office visits, urgent care centers, and retail walk-in clinics.
For all other services, you are responsible for meeting an annual deductible before the plan pays benefits:
- In-network
  Employee only: $1,050
  Employee + one: $2,100
  Employee + two or more dependents: $3,150
- Out-of-network
  Employee only: $2,100
  Employee + one: $4,200
  Employee + two or more dependents: $6,300
After you meet your deductible, the plan pays 70% (in-network) and 40% (out-of-network) for most services.

Basic-

You can use any provider, but you'll pay a lot less when you use in-network providers.
Preventive care is covered 100% (in-network).
You pay a $25 copay for in-network primary care physician office visits, urgent care centers, and retail walk-in clinics.
For all other services, you are responsible for meeting an annual deductible before the plan pays benefits:
- In-network
  Employee only: $800
  Employee + one: $1,600
  Employee + two or more dependents: $2,400
- Out-of-network
  Employee only: $1,600
  Employee + one: $3,200
  Employee + two or more dependents: $4,800
After you meet your deductible, the plan pays 80% (in-network) and 40% (out-of-network) for most services.

Buy Up-

To receive benefits, you must use in-network doctors and facilities.
Out-of-network care is not covered (except for emergency room and ambulance services).
Preventive care is covered 100% (in-network).
You pay a $25 copay for in-network primary care physician office visits, urgent care centers, and retail walk-in clinics.
You pay a $50 copay for in-network specialist office visits, diagnostic tests, labs, x-rays and some other services.
For all other services, before the plan pays benefits, you are responsible for meeting an annual deductible:
- Employee only: $600
- Employee + one: $1,200
- Employee + two or more dependents: $1,800
After you meet your deductible, the plan pays 90% for most in-network services.

Prescription:

	Generic	Preferred brand name	Non-preferred brand name
Buy-Down	30-day supply: $10 copay* at any network retail pharmacy. 90-day supply: $25 copay through mail order or pickup at a CVS/pharmacy.	30-day supply: You pay 45% ($30 to $100 per prescription) at any network retail pharmacy. 90-day supply: You pay 45% ($75 to $250 per prescription) through mail order or pickup at a CVS/pharmacy.	30-day supply: You pay 60% ($50 to $200 per prescription) at any network retail pharmacy. Mail order: You pay 60% ($125 to $500 per prescription) through mail order or pickup at a CVS/pharmacy.
Basic	30-day supply: $10 copay* at any network retail pharmacy. 90-day supply: $25 copay through mail order or pickup at a CVS/pharmacy.	30-day supply: You pay 30% ($30 to $150 per prescription) at any network retail pharmacy. 90-day supply: You pay 30% ($75 to $375 per prescription) through mail order or pickup at a CVS/pharmacy.	30-day supply: You pay 45% ($50 to $250 per prescription) at any network retail pharmacy. 90-day supply: You pay 45% ($125 to $625 per prescription) through mail order or pickup at a CVS/pharmacy.
Buy-Up	30-day supply: $10 copay* at any network retail pharmacy. 90-day supply: $25 copay through mail order or pickup at a CVS/pharmacy.	30-day supply: You pay 15% ($30 to $200 per prescription) for 30-day supply. 90-day supply: You pay 15% ($75 to $500 per prescription) for 90-day supply.	30-day supply: You pay 30% ($50 to $300 per prescription). 90-day supply: You pay 30% ($125 to $750 per prescription) for 90-day supply.

noffgurl · November 2014

Dental:

noffgurl · November 2014

noffgurl · November 2014

For some reason I can't post the dental part, but there are two options one that only covers preventative stuff and then 80/20 and the other seems to cover everything 100% but with a copay. I can't find where the prices are listed for any of these plans.

noffgurl · November 2014

An FSA is offered as well with contribution amounts from $100-2000. There is also a 401(k) offered, but I have no idea how to use that.

vlagrl29 · November 2014

You want to find a plan that is PPO, has a reasonable co pay to primary doctors, covers preventative care and has a low deductible. Pay most attention to max out of pocket for a family because that is the most you guys will pay out of your bank regarding your medical expenses every year. After you meet that, it is good to have a plan that pays 100% of anything over that amount that you meet. Rarely will you meet the full deductible, but with a pregnancy and birth you sure will and then some. Once you meet your individual deductible you can get everything else medically related to you covered at 100%. I've already met mine for the year ($2,200) because of my hernia surgery but I'm pretty healthy so go figure I haven't needed to use it.

Then you also want to pay attention to prescription co pays, what you will pay for generic, etc. Also check to see if you have any other benefits like chiro, physical therapy etc.

Dental is kind of a separate thing for us. All we care about is that all cleanings and X-rays are covered 100%.

noffgurl · November 2014

cupcait927 said:

KatieCutie05 said:

HSA - An IRS run health savings account that you contribute to pretax and then you can use that for all qualified medical expenses - it carries over each year and once you reach a certain balance it doubles as an investment so you can earn money on it. Usually only available with High Deductible insurance plans (although not all) Some companies don't offer them... some give you a certain amount in them - it varies. You can adjust your contribution as much as you want throughout the year - up to a certain amt.

FSA - A Flexible spending Account is an account used strictly for that years medical expenses - you choose a preset amount at open enrollment and cannot be changed after that. Its also put in pretax. But if you don't use it by the end of the year - you lose it.. these are available with any health plan you choose generally.

PPO vs HMO i'm not entirely sure but PPO's generally have a deductible and then once the deductible is hit - you pay a certain percentage of all your expenses. While HMO's have a set copay for doctors visits etc.

The bolded isn't really correct. PPO and HMO are different types of coverage options and networks available. PPO stands for Preferred Provider Organizations. This means that there are doctors that participate with your insurance carrier and using those doctors will get you the best rate. However, PPOs will also cover you if you choose to use an out of network doctor, but at a lesser rate. You're still getting insurance coverage, but the provider can balance bill you for whatever insurance doesn't cover. HMOs are much more selective, no out of network coverage, and the range of services can be limited. It doesn't really have anything to do with high deductibles or copays. PPOs can be copay, hybrid or HDHP. HMOs just tend to be copay plans.
FSA are flexible spending accounts. They can be used on anything medical, dental or vision. You can google eligible FSA items online. It does not rollover and you lose whatever you don't spend by the end of the year. Just be careful - if you have an HDHP plan, you cannot use your FSA on medical expenses, only dental and vision. FSAs are best if you have planned expenses throughout the year, such as monthly prescriptions, glasses or contacts, scheduleded surgery or braces for kids. All of the money in an FSA is available day one of the new plan year, even if you haven't made any contributions into the account yet.

HSAs are great. If your H's employer offers one and you have an HDHP plan, definitely contribute into an HSA. HSAs are individual bank accounts that you own. If your H leaves his job, you can take your HSA account with you. There are guidelines on what you can contribute (easy to google and you should've gotten that info with the OE stuff) and can be used in conjunctions with HDHP plans (most are eligible, some are not). You cannot contribute to an HSA if you are in a copay plan, but if you have HSA funds from a previous HDHP plan year, you can use that money on copays, etc. You can also use HSA funds for dental and vision as well.
It's not correct to say that your HDHP plan did not cover anything. While your out of pocket cost is higher on an HDHP plan, meaning you may pay $80 at the doctor instead of a $25 copay, you are still paying a negotiated amount decided upon by the insurance carrier. Without insurance, your doctor could charge you much, much more. The are limited as to what they can bill you based on your insurance. If you do decide to choose another HDHP plan over a copay plan, think about putting the difference between the per pay deductions of both plans into an HSA, so that you can start to build the account up.

*I work for an insurance broker so I work with this stuff every day.

The reason I say this is I was billed $1200 for a regular well-woman and the insurance covered $100 of it. Yes $100-I have the bill. H had to go to a specialist and the insurance refused to cover any of it and so we have to come up with $660 for that. We never persued that care afterwards because we simply couldn't afford it. The $660 was just the first check up/consulation visit with the specialist. H had to use a chiropractor for awhile, using the insurance meant spending $120 per visit. Finally, the billing/clerk asked us if we would rather pay the cash price and didn't use insurance. We did since cash price was $40 per visit. We had the cheapest plan with United Healthcare that year.

strickland8052 · November 2014

In my opinion, the most important things to consider are the following (in no particular order):

1. Premiums - Premiums are the amount that you pay every month for the health insurance. Note that if the plan has a cheaper premium, the insurance company is making up for that "loss" somewhere else. As a result, below are some other things you need to consider before just grabbing the "cheapest" plan.

2. Doctors - Does each insurance plan cover your favorite doctor? If you have a specific doctor that you want to see, then you need to make sure he or she is "in network" for the plan that you are considering. Most plans allow you to search for doctors in network by name or specialty. Choosing a doctor that is "in network" means you will ultimately pay less than you would if you went to a doctor that is "out of network". If you aren't picky about doctors, then you can choose your insurance based on other factors and just make sure you select your doctor from the plan's list of "in network" doctors. Some plans will have cheaper premiums, because they have a smaller list of "in network" doctors. Other plans might have higher premiums, because they have a very broad list of "in network" doctors.

2. Deductibles - This is the amount that you will pay for medical care out of your own pocket, before the insurance starts paying. For example, let's say you have a $1500 deductible. You get hurt and go to the emergency room. The bill ends up being $1400. You owe the full $1400, because you have not met your deductible yet. As another example, let's say your emergency room bill ends up being $10,000. At this point your deductible will be met. The first $1500 is solely your responsibility for paying. The rest will be split between you and the insurance company, based on what percentage they pay. Typically, a lower premium plan where you pay less each month will likely have a higher deductible. On the other hand, if you pay more every month for your insurance, you may have a lower deductible.

3. Percentage - After your deductible is met, the insurance will pay a certain percentage of your medical bills. Higher premium plans tend to pay a higher percentage than cheaper plans. However, most plans also have an out of pocket maximum.

4. Out of pocket maximum (also known as OOP) - This is the most that you will ever have to pay for medical care under any given plan. Once you pay that out of pocket maximum, insurance starts paying 100% for in network providers. (Under some plans out of network providers are just not even covered at all). Once again, plans have different out of pocket maximums. Higher premium plans tend to have lower OOP than cheaper plans.

5. Co-pays - This is the amount that you will usually pay as soon as you walk into the doctor's office. It can be around $25 - $100, depending on the plan and if you are seeing a specialist or regular doctor. The co-pay is NOT considered in your deductible. It is however considered in your OOP maximum.

*Note - After "Obamacare", insurance plans are supposed to cover all preventative care for free. This includes your annual visit to the OB/GYN. I believe that you still pay a copay for preventative (I'm not sure though), but you definitely do not pay anything else after that.

Let's provide an example for all of this. Let's say you have an emergency that costs $100,000 total with an in network provider. You have insurance with a $1,500 deductible, a $100 hospital co-pay, a $6,000 in network OOP maximum, and insurance pays 70%. When you go into the ER, you automatically pay the $100 co-pay. You then owe the first $1500 of the bill to cover your deductible. That leaves an additional $985,000 to be paid between you and insurance. Insurance pays 70%, so that is $68,950. If you had no OOP, you'd have to pay $31,050. BUT, since you have a $6,000 OOP and already paid $100 of that towards your co-pay, you will only have to pay $5,900. Hope that didn't get too confusing. Also note that all of this starts over again the following year, so if you meet your deductible in December.. you have to start all over again in January.

Overall, deciding on insurance is all about evaluating how much money you are prepared to pay in the event of an emergency. It is also good to consider how likely you are to need medical treatment. My husband and I are generally healthy and have a decent emergency fund, so I tend to opt for the cheaper plan, knowing that if, in the unlikely event that we did need care, we would have enough in our e-fund to cover the OOP maximum. However, next year's open enrollment I plan on getting a much more expensive plan because we will be TTC that year and I know pregnancy issues can and likely will be significant. If H and I had like no savings, I'd probably also choose a more expensive plan because then I'd know we couldn't afford much OOP maximum or a high deductible.

Note- I'm speaking very generally here. Not all cheaper plans mean smaller network, higher deductibles, higher copays, and higher OOP, but there is a good chance they do. They insurance company has to make their money in one way or another.

blondie42107 · November 2014

The reason I say this is I was billed $1200 for a regular well-woman and the insurance covered $100 of it. Yes $100-I have the bill. H had to go to a specialist and the insurance refused to cover any of it and so we have to come up with $660 for that. We never persued that care afterwards because we simply couldn't afford it. The $660 was just the first check up/consulation visit with the specialist. H had to use a chiropractor for awhile, using the insurance meant spending $120 per visit. Finally, the billing/clerk asked us if we would rather pay the cash price and didn't use insurance. We did since cash price was $40 per visit. We had the cheapest plan with United Healthcare that year.

Are your providers in-network? I have an annual with my OBGYN and I've never had a pre insurance amount even close to that. Was is a general yearly physical?

noffgurl · November 2014

blondie42107 said:

The reason I say this is I was billed $1200 for a regular well-woman and the insurance covered $100 of it. Yes $100-I have the bill. H had to go to a specialist and the insurance refused to cover any of it and so we have to come up with $660 for that. We never persued that care afterwards because we simply couldn't afford it. The $660 was just the first check up/consulation visit with the specialist. H had to use a chiropractor for awhile, using the insurance meant spending $120 per visit. Finally, the billing/clerk asked us if we would rather pay the cash price and didn't use insurance. We did since cash price was $40 per visit. We had the cheapest plan with United Healthcare that year.

Are your providers in-network? I have an annual with my OBGYN and I've never had a pre insurance amount even close to that. Was is a general yearly physical?

Yes the providers were in network-I made sure of that. Mine was a general with some blood work. His was first a general-bill wasn't bad, then from the results of that he had to go to specialist. The specialist was in network.

vlagrl29 · November 2014

No you don't pay a co pay for preventative - it is covered 100% and has been for the last couple years or so.

cupcait927 · November 2014

noffgurl said:

blondie42107 said:

The reason I say this is I was billed $1200 for a regular well-woman and the insurance covered $100 of it. Yes $100-I have the bill. H had to go to a specialist and the insurance refused to cover any of it and so we have to come up with $660 for that. We never persued that care afterwards because we simply couldn't afford it. The $660 was just the first check up/consulation visit with the specialist. H had to use a chiropractor for awhile, using the insurance meant spending $120 per visit. Finally, the billing/clerk asked us if we would rather pay the cash price and didn't use insurance. We did since cash price was $40 per visit. We had the cheapest plan with United Healthcare that year.
Are your providers in-network? I have an annual with my OBGYN and I've never had a pre insurance amount even close to that. Was is a general yearly physical?

Yes the providers were in network-I made sure of that. Mine was a general with some blood work. His was first a general-bill wasn't bad, then from the results of that he had to go to specialist. The specialist was in network.

You shouldn't have had a $1,200 for a yearly check up, unless they did some major testing along with the visit. It just doesn't make any sense, knowing what I know about insurance. Did you talk with anyone, like the insurance company or the doctor's office, to see why the bill was so high?

noffgurl · November 2014

No, I figured it was normal and have just been trying to pay it off. All that happened was a pap and a blood draw.

vlagrl29 · November 2014

noffgurl said:

No, I figured it was normal and have just been trying to pay it off. All that happened was a pap and a blood draw.

Are you still paying on it? I would call your doctor and negotiate the shit out of that bill. It's ridiculously high.

noffgurl · November 2014

Yes we are, I will do my best.

brij2006 · November 2014

noffgurl said:

No, I figured it was normal and have just been trying to pay it off. All that happened was a pap and a blood draw.

Since you're still paying on it, you may be able to call up the insurance company and have them do some investigating about the coverage of what was done during that routine exam and why it was so much.

The only way I could see this being somewhat expensive is if they bundled the billing together for both your pap and the bloodwork. It is very possible that the bloodwork was not paid for by them because in their plan it goes under the deductible. So if that had not been met, then the charges for the bloodwork goes toward that. The $100 they covered, was likely for the pap.

This is coming from someone who wrote out a check for $790 for 2 pregnancy tests at the hospital to confirm our pregnancy and 48 hour growth. The insurance paid out $0 for that bloodwork, but the $790 is applied to my $1,000 deductible. Yes it sucks, but the deductible comes into play with anything that isn't preventative care.

brij2006 · November 2014

After reading all of your options and your situation, here's what I would choose:

A low deductible plan, and contribute to an HSA if you can. If you intend to TTC within the next couple of years, then you may as well get on a low deductible plan now. Also, if I'm remembering right your income isn't that large and you're trying to pay down existing medical debt. So it may cost a bit more on the monthly payment basis than a high deductible plan, but if you were to need to use it, it would be better for your current situation to need to pay out the least amount of money possible.

Also, you mentioned about you and your H needing assistance if you do TTC. I would definitely try to dig a bit deeper and have your H ask HR if any of these cover infertility. It is very common for many plans to not cover infertility, and trust me you will thank yourself later. Fertility treatments (and even just diagnosis) is expensive. We did not have coverage 1 year ago and between the testing to diagnose my infertility, 1 round of Clomid treatment, getting pregnant, then miscarrying the baby. None of which was covered under insurance (except the pregnancy part), we paid $7,000 out of pocket. That even included discounts for paying the bill to the specialist in full. We would have happily paid an extra $50/month on our insurance plans to not need to worry about anything but our deductible or maximum OOP in order to get and stay pregnant.

formerlyGDaisy09 · November 2014

noffgurl said:

No, I figured it was normal and have just been trying to pay it off. All that happened was a pap and a blood draw.

The only way I can see you paying for this is if the pap you received wasn't standard of care, in which case your OBGYN should have discussed that with you. I believe that now for women with only one partner standard of care for Pap is every 2 or 3 years.

As far as the rest of your insurance decisions go, how much care do you use in a year? are you a low utilizer, meaning that you get an annual check-up and you need to see your pcp maybe one or two other times a year? or do either you or your H have any chronic conditions that would cause you to require services from a specialist a few times a year? a PPO (a Preferred Providor Organization) will give you higher premiums but lower costs per-visit and for prescriptions, if you have several visits a year and/or have a few prescriptions you use the extra cost in premium is probably made-up in savings on services.

I generally go with my company's PPO plan with a lower premium and slightly higher max out of pocket and deductible. I'm a fairly low utilizer with no chronic conditions. I usually see my PCP for an annual check-up and generally have a few issues that arise during the year that may require a specialist or extra visit to my PCP. ex. this year I had a knee injury in January (PCP visit, no follow-up), a mole removed in april (dermatology and pathology involved), a visit for what's apparently called a neurofibroma in September(PCP visit, no follow-up), x-rays for a possible stress fracture, and blood work because I've had my period once since March. I have also used the counceling and PT offered by my insurance in the past, and I'd much rather pay the $20 co-pay when I have a sports injusry that requires 3x a week follow-up (this happened in 2012) than have to pay co-insurance or the high-deductible rate.

Basically I took my use of services and what H and I have in savings versus what it would cost on for premiums each month into account. some years I win and save more on services used and some years I loose and spend more on premiums than I use the insurance.

If you're offered an FSA consider putting some money (pre-tax) into that to cover co-pays, prescriptions, over the counter meds, and medical equipment. same goes for an HSA if you go with a high deductible plan. Remember funds put in an FSA are use them or loose them, so be realistic about what you use in a year (I put $1000 in mine, I wear contacts, generally need new lenses in my glasses, and usually used what's left on co-pays, over the counter meds, etc.) HSAs roll-over year to year.

However, if you only make a couple visits to your PCPs a year you're probably better off with a lower premium and stashing the savings away to pay for the services you do use.

Either way you should try to make sure you have your Max out of pocket in savings so you're covered in the event that you and your H experience a major medical event in the next year.

formerlyGDaisy09 · November 2014

AprilH81 said:

I'm very confused about something and since you guys are talking insurance I thought I would ask.

Note, potentially stupid question follows...

I always thought that OOP max meant that NO MATTER WHAT that is the most you would ever have to pay during a plan year. Why would I have to pay my deductible in addition to the OOP max?

Example: Having a baby...

My plan (using fake numbers) says that I have a 1,000 deductible, after that it pays 80% and then 100% after hitting the OOP max (3,000).

If I have a baby and the total bill is $10,000, wouldn't I only have to pay $3,000 (OOP max) no matter what? I would pay the first $1,000 of expenses to meet my deductible, then 80% of what is left, up to an additional $2,000, getting me to the $3,000 OOP max.

you are right. you will not pay more than the individual out of pocket maximum. just remember your H also has his own OOP max, and you may have some expenses that are baby's expenses, your baby will have their own OOP max, all your expenses also count towards your family (or whatever they call it) OOP max.

H and I also partially chose our plans with OOP maxes in mind, right now we have enough in savings to cover both OOP maximums.

brij2006 · November 2014

@aprilH81 It all depends on how your policy read. The new ones under ACA are the max OOP for everything (deductible, co-pays, etc). The policies that are grandfathered in usually have the co-pay first, deductible next, and lastly the max OOP as your co-insurance.

Example: My insurance last year was set up the same as yours. However, it was not under ACA. So our pregnancy a year ago would have had the $1,000 deductible, $3,000 max OOP, and the $25 co-pay for each doctor visit throughout the pregnancy. We budgeted $5k total.

This year we have a new insurance plan and our co-pays for office visits, deductible, and the 20% all fall under the max OOP. So now we're planning for the $3k max.

formerlyGDaisy09 · November 2014

brij2006 said:

@aprilH81 It all depends on how your policy read. The new ones under ACA are the max OOP for everything (deductible, co-pays, etc). The policies that are grandfathered in usually have the co-pay first, deductible next, and lastly the max OOP as your co-insurance.

Example: My insurance last year was set up the same as yours. However, it was not under ACA. So our pregnancy a year ago would have had the $1,000 deductible, $3,000 max OOP, and the $25 co-pay for each doctor visit throughout the pregnancy. We budgeted $5k total.
This year we have a new insurance plan and our co-pays for office visits, deductible, and the 20% all fall under the max OOP. So now we're planning for the $3k max.

This may have been rhetoric from the HR department at my company to explain increased premiums, but I got the impression that it is now required for co-pays/co-insurance to count towards the OOP maximum. besides that there were no changes to our insurance options this year.

brij2006 · November 2014

AprilH81 said:

Okay, the grandfathering in might explain why DH's policy (we are both doing open enrollment now) had a foot note that he needed to get the deductible and add the out of policy max to get the TOTAL out of pocket cost (which is really confusing with the terminology they use).

We are TTC now, so open enrollment was a little more complicated trying to figure out what is the best plan(s) for us.

Out of curiosity, does anyone know what kind of expenses are billed to the baby? I thought that everything just rolled up into the L&D costs and subject to our OOP max. I didn't think about the baby (who wouldn't even be covered at the time of birth since the baby has to be born to be added to a policy) having their own cost...

The way my insurance (BCBS) explained it to me, everything would be bundled together in one lump sum billing. Baby would be covered under my care for the 24hr vaginal birth time or 36hr c-section time. If baby has to stay beyond that or has any time in the NICU, then it will be billed separately from my care and my family deductible and max OOP would apply.

blondie42107 · November 2014

AprilH81 said:

brij2006temporarily:

AprilH81 said:

Okay, the grandfathering in might explain why DH's policy (we are both doing open enrollment now) had a foot note that he needed to get the deductible and add the out of policy max to get the TOTAL out of pocket cost (which is really confusing with the terminology they use).

We are TTC now, so open enrollment was a little more complicated trying to figure out what is the best plan(s) for us.

Out of curiosity, does anyone know what kind of expenses are billed to the baby? I thought that everything just rolled up into the L&D costs and subject to our OOP max. I didn't think about the baby (who wouldn't even be covered at the time of birth since the baby has to be born to be added to a policy) having their own cost...

The way my insurance (BCBS) explained it to me, everything would be bundled together in one lump sum billing. Baby would be covered under my care for the 24hr vaginal birth time or 36hr c-section time. If baby has to stay beyond that or has any time in the NICU, then it will be billed separately from my care and my family deductible and max OOP would apply.

That makes sense... I asked by GYN at my last appointment and she said that they lumped everything together too, I assumed that included any of baby's expenses for a "normal" delivery until something earlier in the thread made me think about it. So many questions to ask...

********
I have two kiddos.

My OBGYN sent me one bill for prenatal care and delivery.

The hospital sent me a bill for my room, care, supplies, labs, etc. Also received a charge for the OR (c-section).

Anesthesiologist sent me a bill (epi and then booster and monitoring in the OR - pushed for two hours and then went for c-section).

Hospital sent me a bill for baby's room, care, labs, etc.

FWIW, the hospital has birth suites however baby and I were both charged room fees - we never used the nursery.

It can add up fast!

@AprilH81‌

I have BCBS. With both kids, the hospital notified our insurance of the births right away. The insurance company adds baby to the policy. No joke ours temporarily said just "baby boy" until we followed up with a social security number, etc. They bill all required tests, care etc needed under baby.

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