Health insurance,so confused...need help!

nygirl07 · March 2009

Ok, this may be a dumb question but can someone explain to me how health insurance works with the deductibles and coinsurance? I've been researching plans and I'm so confused. If it says there is a $30 copay for Dr's then a $50 for specialist I know that's what you pay for that but where does the $1000 deductible come in and 20% co insurance? Are they normally only in situations where you are in the hospital? And how about out of pocket expenses?

I never go to the Dr's other then my yearly with my OBGYN and I don't take prescriptions...but I want a plan that covers me for maternity care. I know if my deductible is 1000 or 2500 I'll pay that up front along with my coinsurance...that I get. But does a deductible have anything to do with your regular yearly visits or OBGYN appts?

For some reason I thought that if you had a $1000 deductible and went to you primary Dr or gyno and the appt cost $170 you would pay that yourself and you would continue to pay all your Dr bills out of pocket until you got to $1000 then the insurance would cover it...now I realize that would be stupid.

So am I right to belive that the deductibe and insurance are for major medical expenses and not your primary Dr or gyno visits.

I feel dumb even asking this but the whole thing confuses me and I use to just get what my job offered so I never shopped on my own for it

TIA

NJBride11808 · March 2009

First, don't feel dumb for asking because insurance lingo is so confusing and so many people sign up for a plan not even knowing what they're signing up for. Your deductible is pretty much any expenses outside of the doctor's office. So if you go to the regular doctor and the doctor diagnoses you with something and you just go home, then you'll pay your $30 copay and that's if. But if you go to the doctor and he says I want you to get some blood work done to rule out such and such, then that blood test cost will go towards your deductible. Once you reach your deductible, then you will probably be responsible for paying a portion of your costs. So it sounds like the insurance company would pay 80% and you would pay 20%. This also applies to hospital stays. I would just check to see what your out of pocket maximum would be as well. Hope this makes sense!

NJBride11808 · March 2009

Also, prescriptions don't go against the deductible, unless you're looking at a high deductible plan!

nygirl07 · March 2009

Thanks! I just called about a plan that covers all the basics of maternity and has no deductible or coinsurance...the only thing is that it only covers up to $500 worth of bloodwork/x-rays and of course you don't know how much that will cost. I also didn't realize that individual plans don't cover any form of infertility treatments which I hope I won't need but I'm assuming that just mean IVF treatments and what not, and not meds like clomid right?

NJBride11808 · March 2009

I have no idea what they put under infertility treatments so I'm not help there. I just wanted to say that $500 of bloodwork/x-rays is not much at all. Those both can be very, very expensive.

Jlynn3 · March 2009

I'm not much help on all the insurance lingo and coverages... but I do know a little bit about the infertility stuff unfortunately...

It all depends on the insurance... some won't cover infertility treatments but will cover the diagnostics which usually includes monitoring for one cycle (so that could include meds...). But others won't even cover that. I would check to see if they will at least cover the diagnostic stuff since it isn't techincally IF treatment... hope that makes sense.

nygirl07 · March 2009

Thanks!! I know the $600 for blood work is nothing...I had blood work done 2 years ago and it cost my insurance over $1000....I want to make sure I get something that covers all the stuff that could happen b/c once I'm there I won't be able to change it.

Jamie: Which insurance carrier to you use and do they cover the meds? I was looking into Horizon and Amerihealth I'll have to call and see what they cover as far as infertility and what not. I'm assuming that if need be I could go to an RE under the specialist co pay but as far as the meds and what not I have clue

m&m2006 · March 2009

from the insurance research i just did for an individual plan in nj...they only cover diagnostics. they won't cover any treatments such as iuis or ivf...and they won't cover the specialty medications involved in these treatments. it sucks.

nygirl07 · March 2009

When you say the cover diagnostics does that mean they would cover things like the cholomid or other medications to aid in ovulation?

Jlynn3 · March 2009

I have Aetna... some of their plans cover IF some don't... lucky me has the plan that doesn't cover it.

They covered all the testing (blood, ultrasounds, HSG, semen analysis, etc) to see what issues DH and I had that were preventing us from getting pregnant. ?It included one cycle of monitoring (ultrasounds and blood-work) and that cycle they did put me on Clomid so it was covered.

From here on out everything is out of pocket... so we are in a stand still pretty much until we save enough for IVF... meds alone could cost 3-4K from what I understand...

Hopefully you won't even have to worry about any of this Kristen! ?

nygirl07 · March 2009

Jame: I hope everything works out for you!!! Thanks for the info.....It always gets me mad they health care can charge you so much to have a baby, like it's not bad enought that it's difficult for you to begin with but they have to charge you an arm and a leg for all the meds and what not.

Health insurance,so confused...need help!

Re: Health insurance,so confused...need help!

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