My health insurance is an absolute joke

[ronandannette]

Lack of treatment or lifestyle choice???

I don't understand what you mean. It's not exactly a "lifestyle choice" to reside in a remote area of a vast country and not have access to services. Or to be assigned a position on a wait-list for specialists and procedures that (while they may not actually be life-threatening) results in life-altering suffering.

 

[kimblebee]

I don't understand what you mean. It's not exactly a "lifestyle choice" to reside in a remote area of a vast country and not have access to services. Or to be assigned a position on a wait-list for specialists and procedures that (while they may not actually be life-threatening) results in life-altering suffering.

Or getting a disease that wasn't caused by lifestyle choices...

 

[rajak73]

Based on this thread alone I'm sure there are tons of people who can't afford healthcare. I know I couldn't afford $1200 a month premiums plus a deductible 5K+++. That's outrageous. If that were the case we wouldn't have health insurance.

Actually, as a small business owner, (me and DW) I would take that, our insurance only went up $350 a month this year from $1050 to $1400 a month with a $10,000 deductible.

False

Yea, before the ACA I was paying $750 a month with a $5000 deductible.

 

[DizBelle]

Why Are You Capitalizing Every Word? Then we must be in the 1%, because our HSA is 100% after the deductible.

Again, we must be in the 1% because our FSA is optional.

I'm not sure what this means. HSA is a health savings account. It is just an account you fund pre-tax to pay for medical costs. I'm not sure what you mean by your "HSA is 100% after the deductible". Unless you are confused by what you are referring to. I think you are referring to a HDHP (high deductible health plan).

 

[sam_gordon]

I'm not sure what this means. HSA is a health savings account. It is just an account you fund pre-tax to pay for medical costs. I'm not sure what you mean by your "HSA is 100% after the deductible". Unless you are confused by what you are referring to. I think you are referring to a HDHP (high deductible health plan).

You are correct. We have a HDHP that is tied with an HSA. If you sign up for the HDHP, the company even gives $750/year (no guarantee, but has the last 4-5 years) in the HSA, plus whatever you contribute. I was simply combining the plans (because that's how it's done at my employer).

 

[DizBelle]

Out of pocket maximums typically DO NOT apply to expenses incurred out of network.

By law (ACA), there are limits on out of pocket maximums. And I don't think in or out of network matters. For 2017, your out-of-pocket maximum can be no more than $7,150 for an individual plan and $14,300 for a family plan. Granted, this is only for essential covered services. But I would think that emergency care after a car accident would be essential and covered.

 

[DisAuntie]

Out of pocket maximums typically DO NOT apply to expenses incurred out of network.

I double checked ours yesterday. Our out of pocket max out of network is the same as out of pocket in network, which is different than our deductible.

 

[Hikergirl]

By law (ACA), there are limits on out of pocket maximums. And I don't think in or out of network matters. For 2017, your out-of-pocket maximum can be no more than $7,150 for an individual plan and $14,300 for a family plan. Granted, this is only for essential covered services. But I would think that emergency care after a car accident would be essential and covered.

My OOP for out of network is almost double what my OOP for in network is.

 

[Planogirl]

This talk about OOP maximum is interesting. I assume that this would depend on state. Anyone here from Texas? Texas is not particularly consumer friendly IMO.

 

[DizBelle]

This talk about OOP maximum is interesting. I assume that this would depend on state. Anyone here from Texas? Texas is not particularly consumer friendly IMO.

I am in Texas and I have an OOP max for both in and out of network.

 

[Hikergirl]

I'm in NY and I just checked and this year my out of network max OOP is more than double my in network.

 

[DisAuntie]

I'm in NY and I just checked and this year my out of network max OOP is more than double my in network.

Both of ours is $8000 for family. Individual for in network is $3000 and individual out of network is $4000.

 

[Hikergirl]

Both of ours is $8000 for family. Individual for in network is $3000 and individual out of network is $4000.

Our family OOP is $13,100 max in and out of network is $28,350
Individual OOP is $6550 max in and $15,750 out.

We obviously try to stay in network and our insurance has partners that are considered in network even though they aren't. My dh has an ongoing issue that started last summer and unfortunately we can't always stay in network for the specialists he has to see.

 

[Planogirl]

Our family OOP is $13,100 max in and out of network is $28,350
Individual OOP is $6550 max in and $15,750 out.

We obviously try to stay in network and our insurance has partners that are considered in network even though they aren't. My dh has an ongoing issue that started last summer and unfortunately we can't always stay in network for the specialists he has to see.

That is rough. You can't always help who you end up seeing.

Have you ever had specialists who try to go beyond the OOP maximum?

 

[Hikergirl]

That is rough. You can't always help who you end up seeing.

Have you ever had specialists who try to go beyond the OOP maximum?

Not yet. Thankfully at this point the bills haven't reached anywhere the maximum. But, its a new year and I have no idea who dh will be seeing. We are really just hoping for a diagnosis so he can stop being shuffled around. Once we get that I think we will make sure to stick in network if its possible.
Last year he took care of the family deductible and almost all of the OOP max but not alot of out of network thankfully. He has to see a couple new specialists and of course the ones we were recommended (to by family and friends) are not in our network. He hasn't decided yet on who to see. I guess in the mean time we just try to rebuild our HSA.

Oh I thought you meant out of network docs trying to go over the maximums.
We haven't had any of our in network docs try. In fact they have all been really great working with us. This is the first time we have ever reached the deductible and nearly reached the in-network OOP max so we weren't really sure how the process would be and if we'd have alot of fighting about bills. So far so good.

 

[DisAuntie]

Our family OOP is $13,100 max in and out of network is $28,350
Individual OOP is $6550 max in and $15,750 out.

We obviously try to stay in network and our insurance has partners that are considered in network even though they aren't. My dh has an ongoing issue that started last summer and unfortunately we can't always stay in network for the specialists he has to see.

Yikes. I only know the exact amounts because DS severely sprained his ankle in early December and we just got the EOB yesterday. We owe $25 for his xray and doctor's visit. Luckily, DS called and asked which hospital at school was in network.

 

[DizBelle]

Not yet. Thankfully at this point the bills haven't reached anywhere the maximum. But, its a new year and I have no idea who dh will be seeing. We are really just hoping for a diagnosis so he can stop being shuffled around. Once we get that I think we will make sure to stick in network if its possible.
Last year he took care of the family deductible and almost all of the OOP max but not alot of out of network thankfully. He has to see a couple new specialists and of course the ones we were recommended (to by family and friends) are not in our network. He hasn't decided yet on who to see. I guess in the mean time we just try to rebuild our HSA.

Oh I thought you meant out of network docs trying to go over the maximums.
We haven't had any of our in network docs try. In fact they have all been really great working with us. This is the first time we have ever reached the deductible and nearly reached the in-network OOP max so we weren't really sure how the process would be and if we'd have alot of fighting about bills. So far so good.

Not sure I get this. How would a doctor go over the OOP max? The doctor bills what the doctor bills. Once you reach your OOP max, insurance should pay whatever it is above that.

One caveat is that it is likely that you OOP max for in network and OOP max for out of network are treated separately except for emergency care.

So if your in network OOP max was $5000 and your out of network OOP max is $15000 then you could be on the hook for $20000 if you use a mix of in network and out of network service providers.

 

[mom2rtk]

The problem is that out of network out of pocket cost can really be anything since non-negotiated providers are not obligated to write off anything above what insurance allows.

 

[keaster]

I just wanted to say that as a Canadian, I do find the American health care system extremely confusing and I feel bad for those who struggle to cover what they need. I honestly find it strange to read of people who have huge bills when they leave the hospital for surgeries or after having a baby.

I was in hospital for 3 days after our daughter was born and the only bill I had was 15 dollars for having a TV in my room! We've had to go to emergency twice for our daughter for injuries, no charge. We rushed my MIL to emergency early one morning when she was dizzy and feeling ill, no charge. My husband has had four surgeries on his throat and we once had to pay for a certain medication that his work insurance reimbursed us for. I'm not trying to say "our system is better than yours" and ours is far from perfect, but it seems like such a foreign concept to me!

 

[mom2rtk]

Not sure I get this. How would a doctor go over the OOP max? The doctor bills what the doctor bills. Once you reach your OOP max, insurance should pay whatever it is above that.

One caveat is that it is likely that you OOP max for in network and OOP max for out of network are treated separately except for emergency care.

So if your in network OOP max was $5000 and your out of network OOP max is $15000 then you could be on the hook for $20000 if you use a mix of in network and out of network service providers.

Most insurance companies pay up to a "reasonable and customary" level for a given service. Anything above that is handled in one of two ways: 1) if they are in network, they are typically obligated by contract to write off anything in excess of that amount or 2) if they are out of network, they can (and will) balance bill for what's left. They have no responsibility to anyone to write that off. And it's between you and the provider, not the insurance company.