Health Insurance Confusion

Finally decided it's time to get myself insured again. I am confused. This thread may cause a headaches.

Hopped on healthcare.gov. Got sent to wahealthplanfinder.org. Looked at plans. Boom down for maintenance (AGAIN this has happened numerous times). Before it went down, I briefly looked through plans from various providers and the cost ranged from about $215-$300 (I'm sure they go higher).

I am 28 and a smoker. I would of course like to keep the monthly payments as low as possible, but $300 is actually not as high as I was expecting. I don't mind having a high deductible, but my understanding is that out of pocket expense is capped at $6350 now. I don't know if you need that information, but there you go.

I understand the deductible. It's like car insurance. If I crash my car, I have to pay X amount and insurance covers the rest, basically the same thing. Deductible goes up, premium goes down. I understand premium (cookies appreciated).

Coinsurance and copay are confusing me at this point. I was looking at two plans, about the same premium (I think $40 different a month). One had a higher deductible (but only by about $1,000) but says 0% coinsurance after deductible for everything. The other was 20% coinsurance after deductible. That 20% coinsurance could add up REAL fast. Have a $50,000 surgery and have to pay coinsurance... Considering a freaking ambulance ride can exceed $10,000...

Plan 1 cheaper premium, 0% coinsurance after deductible and $20 office visits. Higher deductible.

Now looking at this, am I to assume that the copay for doctors visit takes effect before I reach my deductible? As in every time I go to the doctor I only pay the copay even if I haven't racked up $6350 deductible? Also WTF are the different tiers under prescription drugs?



Plan 2 more expensive premium, 20% coinsurance, same cap for maximum out of pocket expense, apparently cheaper drug costs before deductible. Difference in deductible seems negligible to me. $1,000 doesn't seem like a lot to me if you consider the alternative can go off the charts.



SOOO... Who in their right mind would choose option 2? People that have a ton of prescriptions but aren't worried about hospital bills?

Copay is throwing me for a loop because I thought generally you had to max out your deductible before the insurance company started paying for anything. So are they saying that an office visit is only going to cost me $20 or whatever even BEFORE I've reached the deductible?

I feel like option 1 is the best for me if I'm correct and the total annual cost would not exceed $6,350 (because no coinsurance).

Any tips, advice, mocking, sympathy for my now fragile mental state or questions about this train wreck thread appreciated. I tried to make my confusion easy to understand.

Geez Domo... Your thread is as silent as an Obamacare appreciation party.

I may know the answer to the copay question, but it does still depend on your policy as to whether it is right or wrong.

My husband's insurance covers all of his doctor visits, specialist visits, and prescriptions, before he meets his deductible. He does pay the copays until he meets the deductible and when he meets that it starts covering the whole visit/prescription cost.

Keep in mind that not all of them may use this method, but it does seem to read (what you posted) that your plan will work the same as his. As for the other stuff... I am as lost as you are.

Can you imagine what a fun time a lot of the older people are having while trying to figure this stuff out? I think they make it confusing on purpose.

I hope you get it worked out soon.



(I couldn't help myself. You posted a pic so I had to jump off the bridge too.)

reply to post by Domo1


Just by your title I knew it had to do with obamacare lolz

reply to post by Domo1


Generally this is how co-pays work. No matter what your deductible is, you are going to pay the co-pay at a regular doctors office, as long as they are covered under your plan. You are going to pay a co-pay for prescriptions that are covered under your plan.

Deductibles start coming into play when you need anything other than BASIC help. For example, you go to an annual appointment at your covered doctor. He orders blood work. The standard blood work is covered, however, due to your conversation, the doctor wants to test for a few things not covered in 'basic' care.

That's where your deductible comes in. Insurance pays for the general blood work, you are responsible for the 'extra' testing. The extra testing counts towards your deductible. Your co-pays don't count towards it.

This is generally how these things work. With Obamacare messing everything up, it may be different.

Another thing, I don't see this in your OP, are you looking for something called total annual benefits or similar? That's important. Say you have a $2000 deductible. You meet it. Insurance starts covering you. Your expenses outside that deductible reach $100k. Insurance says: Hey it's your ball again, we've paid as much as we're going to pay for you this year!

This happened to a guy I was dating once. It sucked so bad, so please look out for it. After he was paying $200 a month insurance, and met a $5,000 deductible, insurance cut him off...wouldn't pay anything til the year rolled around which was still like 3 months away...AND, guess what, gotta meet that $5,000 deductible. Again. We paid out our butts for them to cover him like half the year. Huge gaps in the beginning where we had to cover it, and at the end, where they said he exceeded his benefits. Please look out for that.

reply to post by Kangaruex4Ewe

Geez Domo... Your thread is as silent as an Obamacare appreciation party.

Appreciate you chiming in (love the roo that is you). Apparently some people have better things to do on a Friday night than help a stranger shop for health insurance. For shame. Those awful Friday night revelers don't know the simple joy of brushing their dog with a glass of wine (err while drinking one, I don't use the stemware to groom the dog) while getting baby punching mad trying to decipher insurance speak. Speaking of babies, I apparently get super sweet coverage for them even though I'm a single male and have yet to spawn. Gonna have to update my eHarmony profile. Swatting the ladies off like flies with this news.

Can you imagine what a fun time a lot of the older people are having while trying to figure this stuff out? I think they make it confusing on purpose.

That's what really bugs me. I'm not the sharpest tack in the euphemism, but I'm somewhat literate. I can't imagine how hard navigating this nonsense would be to someone that's just a tad slow. Old, dumb or illiterate. Not fair. And if you just shop off monthly payments you can really screw yourself. That 'coinsurance' is freaking scary. So is the no authorization needed to go out of network and have to pay a ridiculous amount. It's really not something to joke about even though I want to because that's how I deal with really screwed up things. Awww you have an alien baby popping out of your chest? Hope you're in network.

Slogging through insurance benefits/coverage sucks. The industry has made sure of that.

Copay. Coinsurance. Deductibles. There really isn't any defined standards for the most part.

I've found a simple source that sort of answered my own questions. Sort of...

What's the difference between copays and coinsurance? Copays and coinsurance are two different ways that you pay for part of the cost of your own healthcare.

--A copay is a flat fee that you usually pay at the doctor's office or when you pick up a prescription. If your plan requires you to pay copays for services, the amounts will be listed on your insurance ID card.

--Coinsurance is a percentage of the service charge that your health plan calculates for you, after you've met your deductible.* You don't usually pay coinsurance at the time of the service. When you see the claim in Quicken Health Expense Tracker, it will show that you owe money, which is the coinsurance (even if you don't see that word).

You will almost never have to pay both a copay and coinsurance for a single expense, but you might have to pay both on a single claim if that claim has multiple expenses. For example, you might pay a copay for an office visit, but while you're there the doctor might perform another service like removing a mole, and you might have to pay coinsurance for that service.

NOTE: Since most people are required to pay the copay at the time of service, Quicken Health Expense Tracker automatically creates a payment showing that it was paid. Quicken Health Expense Tracker does not automatically create payments for coinsurance.

* Generally speaking, you are responsible for 100% of the Amount Allowed for a service until you've paid an amount equal to your deductible. After that, your health plan pays the majority of the costs -- perhaps 80% -- but you are still responsible for the remainder. If you have a lot of medical expenses in one year, you may pay enough to reach the maximum out-of-pocket limit set in your policy, after which your health plan will pay 100% of the costs for the rest of that plan year.

Note that this is a very general and simple explanation. Read your policy or talk to your HR department about exactly how your insurance works.

Source

Sorry that the link is to a site that sells a product. But, it was the most simple and best explanation that I could find. Even with that little bit of information, it is wise to read the explanation of benefits BEFORE you decide on a policy. Some insurers will NOT apply your copay towards your total out of pocket expenses. That means that even if you have paid for doctor visits and prescriptions in an amount that exceeds your deductible/out of pocket limit, if your insurance doesn't count that towards your deductible/maximum out of pocket, you still have to pay. (I've heard that blue cross is the devil in this regard )

I really hope that anything above helped a bit. But, I'm sure that I just muddied the water even more for you. Health care doesn't need to be so complicated. But, we are who we are and nothing is simple here.

I have been putting off getting coverage myself and know I'll have to look into it soon. I dread this soooooooo much! You pay enough for coverage and it only covers so much.

As far as what I know or have been told, co-pays do count toward your deductible.
And the MAXIMUM out-of-pocket you pay per year is $6350.

On the co-pays: until recently, I had AWESOME insurance and the cop-pays ALWAYS went to the deductibles.

If I were you, I would contact one or both of the companies you're interested in.....and ask them directly to explain co-pays, co-insurance and the like.
The stand to be getting a lot of money from you, and want as many insureds as possible and should be happy to answer questions for you.
So, write out your questions and call them Monday morning ...well, maybe Tuesday would be better as it seems whoever you want to call on Monday morning is busier......

Domo1
reply to post by Kangaruex4Ewe

 

Appreciate you chiming in (love the roo that is you).

And I love the p...er kitty that is you Domo.

Apparently some people have better things to do on a Friday night than help a stranger shop for health insurance. For shame.

I don't know why they would consider that "better things". I question their judgement of fun and loyalty.... maybe even their compassion if that is the case.

I apparently get super sweet coverage for them even though I'm a single male and have yet to spawn. Gonna have to update my eHarmony profile. Swatting the ladies off like flies with this news.

Oh yes. You are Kobe Beef in a sea of ground chuck, never doubt it. Without previous (demon) spawn, your stock just skyrocketed for sure. You'll have to hire help to keep the ladies off. If that is the case I am available nights and weekends.

That's what really bugs me. I'm not the sharpest tack in the euphemism, but I'm somewhat literate. I can't imagine how hard navigating this nonsense would be to someone that's just a tad slow. Old, dumb or illiterate. Not fair. And if you just shop off monthly payments you can really screw yourself. That 'coinsurance' is freaking scary. So is the no authorization needed to go out of network and have to pay a ridiculous amount. It's really not something to joke about even though I want to because that's how I deal with really screwed up things. Awww you have an alien baby popping out of your chest? Hope you're in network.

It is scary. I am not looking forward to it and probably will not be able to afford it myself. I will be one of those "paying the penalty" tax I suppose. My quote was far more than I could have had insurance for already. I didn't have it, because I couldn't afford it. Now with ACA.... I still can't afford it. It is more than it would have been had I purchased it through my husband's employer. The whole thing is a shiite storm (pardon the expression) in my opinion.

I would say I think it's going to fail.... but I am not sure they will let it fail regardless of the "price" we will all pay for it in the end.

Kangaruex4Ewe
I would say I think it's going to fail.... but I am not sure they will let it fail regardless of the "price" we will all pay for it in the end.

Thing is, now that millions have had their insurance canceled for a variety of reasons...allowing it to fail would render all of these formerly insureds without insurance, and earning too much for Medicaid.

It would be a disaster of mammoth proportions.
I think it might implode the country.

What about the people who don't make enough to afford any insurance under Obama's plan? Example: Homeless People, People without any means of earning any income?

reply to post by Domo1


Do you have on going medical issues, problems that only western medicine can address? Concerned about breaking a new law or having the IRS knocking at your door?

Eat healthy, think healthy, and save your 300 per month.

I don't use or need doctors for my health, they are however handy in trauma care, broken legs and other unexpected things. The last time I was in an emergency room, I paid cash at the same rate that the insurers pay, which took only a very small bite out of my savings that have been set aside for such things.

I can only speak for myself, and the ACA is just another useless tax on me, and I will not pay for the bad health practices of other folks or the illegals that are exempt from the ACA.

reply to post by Witness2008

Do you have on going medical issues, problems that only western medicine can address? Concerned about breaking a new law or having the IRS knocking at your door?

I don't really, but I'd rather be safe. Kind of like car insurance. I don't plan on wrecking my baby, but it's happened before. Not concerned about the IRS really, the fine is negligible.

I consider health insurance to also be asset insurance. One bout of illness could completely wipe out my assets and put me into debt. We've all heard stories of people having to clean out their portfolios and sell houses to pay for medical bills. Not only do I want to protect myself and well being, but also my investments.

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Appreciate everyones help. I went for the first option listed. It seems like the right choice as I'm not concerned with a high deductible, but it gives me doctors visits on the cheap and protects me from having to pay coinsurance. $218 per month. Should kick in by the 15th and will be a weight off my shoulders.

reply to post by Kangaruex4Ewe

You'll have to hire help to keep the ladies off. If that is the case I am available nights and weekends.

It really does get exhausting. I could use an assistant. Fax me your resume (you already got the job, it's just a formality HR makes me go through, you have the job).

DontTreadOnMe

It would be a disaster of mammoth proportions.
I think it might implode the country.

It's "disturbing" how much of a disaster it is already shaping up to be. It's the president's baby and no matter how "disturbing or distasteful" the outcome may be... it is too big to fail.

Rest easy.