I hope people don’t think I’m too silly for posting this, but health insurance has always been a little confusing for me with the deductibles and such, I start feeling like this is intentional. My husband works and I’m a stay at home mom of 2. For years, the health insurance he got through work was covering at least a portion of any dr visits we needed, but we had a $30 copay. He switched jobs about a year ago and we are now with Blue across of Idaho. The deductible recently went from $700 to $900, and they pay literally nothing. Since the beginning of the year, every dr appointment I or my husband has had, we’ve had to pay in full. Every time I need to take my kids into pediatrician (random rash or wellness visits) we get hit with a $200 bill at least and it shows insurance covered $0. I’ve called and inquired about this a cpl times and they basically say we haven’t reached our deductible so it is what it is. When I went online it said we’ve paid $600/$900 of our deductible this year. Is this normal that we are paying thousands for insurance plus getting hit with the full bill? I know it might be a silly question. How is this insurance SO MUCH WORSE than our last insurance? I don’t recall EVER getting full medical bills nearly every other month until now. Also, I recently filed a claim for the midwifery I paid for while I was pregnant with my son last august. I filed a claim for my prenatal and postpartum care, and I filed another claim for the care of my son. They sent me a rejection letter so I called to ask why the claim was rejected and they said there was no sign of me ever having filed a claim, but by the sound of my rejection letter, they I was denied because they ‘believed’ I was trying to say my INFANT had gotten pregnant and gave birth. It makes no sense and I don’t know where to go with them from here. I filed an appeal about the midwifery thing in early April and have heard nothing back.
Explain it to me like I’m 5 please! Insurance covers nothing.
byu/DegreeComfortable198 inInsurance
Posted by DegreeComfortable198
7 Comments
I do think the Healthcare industry makes it needlessly challenging to understand. My pharmacist saved me because my doctor gave me a script for a particular brand inhaler (bronchitis) that would have cost $90 OOP where there was another brand that cost $0. If the pharmacist was just “doing their job” and releasing what was prescribed I would have lost $90.
You may have a per person deductible, a family deductible, and in- vs out-of network maximum out of pockets at play here.
You have to pay the deductible 100% before insurance really kicks in. So whatever the final bill is after the insurance contracted rate applied is, you pay. Then you typically have to pay what’s called coinsurance which is a percentage of every bill. For example, my family plan has a $4500 deductible and a $6800 max out-of-pocket that is reached by paying 20% coinsurance. Coinsurance means every bill after i get after $4500, i pay 20% and insurance pays 80% of until I hit $6800. Then after that insurance covers 100%. Your prior policy may have had co-pays instead of full deductible…there could be a number of reasons.
>Also, I recently filed a claim for the midwifery I paid for while I was pregnant with my son last august. I filed a claim for my prenatal and postpartum care, and I filed another claim for the care of my son
Assuming in-network providers, insurance isn’t going to accept a claim from the subscriber for any reason. Providers are the ones with the expertise to file claims with the needed information and proper coding, and it’s their contractual obligation to do so on the behalf. If you’re choosing out-of-network provides, then yes, as well as a terrible financial decision the burden is on you to figure out how they want your claims submitted, asuming you have any out-of-network benefits. The best option is to ask the provider for a “Superbill” to submit as a claim.
>I’ve called and inquired about this a cpl times and they basically say we haven’t reached our deductible so it is what it is
So it is being covered- covered subject to your deductible. A $900 deductible is still low by modern standards, so if you don’t like it about the only option is for him to talk to HR about different benefits next year, or find a job with benefits more to your liking.
annual wellness visits should be more or less fully covered by insurance regardless of detuctible. are your doctors in-network?
It’s convoluted for a few reasons:
1. Health insurance originally started as accident insurance or savings accounts with hospitals. The modern concept of go to the Dr for everything and expect insurance to pay is a “new” concept (within the last 40-50 years).
2. Using health insurance for small things that are affordable out of pocket adds admin costs for simple things. So if insurance paid 100% of your medical bills you would be paying 140% of expected amounts, and some risk premium for accidents or potential big bills. Deductibles is meant to be risk sharing so they can keep costs lower. The more you pay the less they have to spend resources trying to administer for you.
3. The confusion regarding billing is because medical insurance can cover or pay for very specific things. So unless a Dr’s office or you complete the claim form the exact way they need, there will be a rejection or delay due to variances in how things can be paid per their contract. It’s annoying AF, but it’s extremely detailed for a reason.
Insurance is a complete shit show and scam
And yes it’s normal. His old employer might have had a really good insurance plan and contributed a lot towards it. The new job, not so much
I’ve switched jobs a lot and been part of 2 corporate restructures. Some companies contribute a lot and give you good insurance while others give you complete crap unless you pay substantially monthly. In my experience smaller companies can afford to give you better insurance, or maybe insurance companies just negotiate differently with them
I have no kids so I’ve never worried about it, but if you support a family you absolutely have to consider the impact of insurance when changing jobs
This will depend on the policy. Some policies pay nothing until the deductible. Then they may have a copay until you reach the max out of pocket. Then after you reach the max out of pocket they cover everything. I would ask to see the plan your family has so you have a better idea.