Maybe I'm the one who is confused - medical insurance

[china mom]

I am in a FB group for people on a certain, not cheap, medicine. Someone posted that their co-pay went way up this month because they had not met their medical insurance deductible. Their response was that they were going to go off the medicine temporarily until after they had met the deductible.

I was wondering if I am the one who is misunderstanding how this works. Lets say my insurance deductible is $500 doesn't that mean that I have to pay $500 out of pocket and then everything (except co-pays) is covered? So, how is going off the medication saving them money if they are still paying $500 for other medical services until it is met?

Then, last night, my podiatrist office calls me and says that they ran my new shows through insurance and found that I had not met my deductible yet and it was $100, do I still want them to order the shoes? While I do appreciate the heads up, it seemed like I was being asked if I wanted to hold off until I had met my deductible. But if that was the case, I would have to pay $100 for my next medical service anyway.

Am I wrong or is everyone else? Math ain't mathing on this one.

BTW, the shoes cost $112 out of pocket online so It is pretty much break even if I need them anyway.

 

[Praying Colonel]

I am in a FB group for people on a certain, not cheap, medicine. Someone posted that their co-pay went way up this month because they had not met their medical insurance deductible. Their response was that they were going to go off the medicine temporarily until after they had met the deductible.

I was wondering if I am the one who is misunderstanding how this works. Lets say my insurance deductible is $500 doesn't that mean that I have to pay $500 out of pocket and then everything (except co-pays) is covered? So, how is going off the medication saving them money if they are still paying $500 for other medical services until it is met?

Then, last night, my podiatrist office calls me and says that they ran my new shows through insurance and found that I had not met my deductible yet and it was $100, do I still want them to order the shoes? While I do appreciate the heads up, it seemed like I was being asked if I wanted to hold off until I had met my deductible. But if that was the case, I would have to pay $100 for my next medical service anyway.

Am I wrong or is everyone else? Math ain't mathing on this one.

BTW, the shoes cost $112 out of pocket online so It is pretty much break even if I need them anyway.

It will depend on the insurance policy and how it pays for meds. Different companies will have different rules.

 

[jeneric997]

Maybe they have a medical procedure in the near future that will cost more than the deductible? We have a very high deductible with a low premium, so waiting would not be an option. We do check prices in the beginning of the year on sites like GoodRX. While it won't count against the deductible, we find it is worth it for a significant discount.

 

[kdonnel]

Traditional insurance generally works something like this:

1. You have an individual and family deductible
2. You have a coinsurance rate
3. You have a max out of pocket individual and family in network
4. You have a max out of pocket individual and family out of network

Some things don't apply towards your deductible, generally those things have a flat copay.

So in your example with a $500 deductible, you would need to know your coinsurance rate as well.

This generally means that the first $500 in medical expenses that are not eligible for a copay are paid by you at 100% and then after the deductible is met you pay the coinsurance amount.

For a $1000 in patient expense with 20% coinsurance that means:
1. You owe $500
2. You also owe 20% of the remaining $500, until you meet you max out of pocket.

So that $1000 in patient expense would be $500 + $500(.20) = $600.

 

[china mom]

Maybe they have a medical procedure in the near future that will cost more than the deductible? We have a very high deductible with a low premium, so waiting would not be an option. We do check prices in the beginning of the year on sites like GoodRX. While it won't count against the deductible, we find it is worth it for a significant discount.

But I am still confused. If my deductible for, let us say regular doctors visits, is $100. I need to have a splinter removed but my deductible isn't met yet so I wait. The next visit I go in for a cold, I pay $100 as my deductable. Now that it is met, I can get the splinter removed at another visit for only my co-pay. OR, I get the splinter taken care of now for $100 and when I catch a cold, it will cost me only my co pay.

It's the same money, isn't it? The only difference is that I put off getting care for the first issue.

I have to meet my pharmacy deductible before my meds are covered but it is the same money if I refill now of refill later after I end up getting other meds and have met the deductible.

 

[tony67]

I thought the copay for drugs is usually unrelated to the deductible, but there are so many bad plans in the market place who knows.

I guess it could be such an expensive drug its separate from the standard copays

The place where you can run into trouble typically is usually at the end of the year when you have maxed what they will cover for prescription drugs, I've had family members run into that and then they stop taking their drugs till the next year (or they skipped enough days though the year if they planned well that they have enough to keep going)

 

[china mom]

Traditional insurance generally works something like this:

1. You have an individual and family deductible
2. You have a coinsurance rate
3. You have a max out of pocket individual and family in network
4. You have a max out of pocket individual and family out of network

Some things don't apply towards your deductible, generally those things have a flat copay.

So in your example with a $500 deductible, you would need to know your coinsurance rate as well.

This generally means that the first $500 in medical expenses that are not eligible for a copay are paid by you at 100% and then after the deductible is met you pay the coinsurance amount.

For a $1000 in patient expense with 20% coinsurance that means:
1. You owe $500
2. You also owe 20% of the remaining $500, until you meet you max out of pocket.

So that $1000 in patient expense would be $500 + $500(.20) = $600.

So, for each $1,000 procedure with a $500 deductible and 20% co-insurance they are paying $600? I thought it was an annual deductible so I pay $600 the first time and then only 20% of the next procedure.

 

[china mom]

I thought the copay for drugs is usually unrelated to the deductible, but there are so many bad plans in the market place who knows.

I guess it could be such an expensive drug its separate from the standard copays

The place where you can run into trouble typically is usually at the end of the year when you have maxed what they will cover for prescription drugs, I've had family members run into that and then they stop taking their drugs till the next year (or they skipped enough days though the year if they planned well that they have enough to keep going)

I confess, I don't really pay attention. I have very good insurance. Once a year, I have to pay a little something for prescriptions when the the policy renews but it is never enough to hurt so I just pay it. I have never hit my make and some of my medications are pretty expensive. I am grateful for my employee provided insurance and it is the reason I am still working.

 

[china mom]

The whole think reminds my of DH when he puts off buying something that we all know we need or will buy eventually because "we already spent a lot of money this month". But, we have plenty of money in the checking account to pay for it. If we are going to spend it next month, why not spend it now, it is the same money next month.

 

[lanejudy]

I understand your confusion...but there are SOOO many different ways that health insurance works in the US, it really is dependent on that individual's specific insurance.

Assuming the deductible applies to both prescription and other healthcare, then generally speaking you are correct. Avoiding the expensive med until the deductible is met only means they need to pay out that much in other healthcare expenses. Possibly the individual relies on an HSA to pay for the deductible expenses, and as the new year rolled around they haven't yet funded the HSA to a point where they can afford full-cost of the expensive Rx out of the HSA.

 

[kdonnel]

So, for each $1,000 procedure with a $500 deductible and 20% co-insurance they are paying $600? I thought it was an annual deductible so I pay $600 the first time and then only 20% of the next procedure.

That is where the annual max out of pocket comes into play.

So assume your annual max out of pocket is $1500, your coinsurance is 20% and your deductible is $500....

Until you had paid out $1500 the coinsurance comes into play.

For example:
$1000 in patient results in $600 owed taking your remaining deductible to $0 and your remaining max out of pocket to $900.

To pay out the remaining $900 you would need to incur another $4500 in medical expenses. ($4500 x .2 = $900).

At that point any additional medical expenses are paid 100% by the insurance company.

 

[Dan Murphy]

Your thinking is correct, @china mom. Rx usually will have separate deductible and copays from other medical care.

 

[lanejudy]

I thought the copay for drugs is usually unrelated to the deductible, but there are so many bad plans in the market place who knows.

It really depends on the policy. Some health plans are "health" only and a separate prescription plan is required, which may have it's own deductible. But others have 1 deductible that applies to all -- Rx, office visits, labs, xrays, inpatient, etc.

The place where you can run into trouble typically is usually at the end of the year when you have maxed what they will cover for prescription drugs, I've had family members run into that and then they stop taking their drugs till the next year (or they skipped enough days though the year if they planned well that they have enough to keep going)

That sounds more like a donut-hole issue with Medicare, not most commercial insurance plans (like most plans through an employer or the state exchanges). Most commercial insurance plans have an out-of-pocket max, and once you spend that maximum then everything is covered for the rest of the year.

 

[SC Minnie]

To me what doesn't make sense for the person that was going to go off their meds until they met their deductible-- do they really need those meds if they can just stop taking until some time in the future? What are the medical consequences of going off the meds all at once? Could that cause other medical issues that would then cost them more in the long run?

 

[lanejudy]

Copay and co-insurance are 2 different animals. While it may seem to be basically the same thing -- it's what you pay out-of-pocket -- how they are calculated is different.

Copay is usually a set fee. Maybe $25 for an office visit or $10 for a generic prescription. It doesn't matter the amount actually charged by the provider, your payment amount is set. There usually is no deductible, copays start from day 1. There typically is no maximum out-of-pocket for copays. (I say typically but I'm sure there are some different plans out there which do, just not most under a copay structure.)

Co-insurance is usually defined as a percentage of the allowed/accepted charge, and usually kicks in after a deductible has been met. This may look like $500 deductible then 20% coinsurance. There may be an out-of-pocket maximum, and once your deductible + all co-insurance adds up to the max then everything is covered 100%.

Some plans may have a mixture of both copays and co-insurance. Often copays for office visit and prescriptions, but deductible and co-insurance for other services such as labs, xrays, surgeries, etc.

And that's just basics. From there you have plans with in-network vs out-of-network coverage, certain services covered/not-covered, restrictions, limitations, etc. Healthcare in the US is one massive jumble of varying coverage. It's really impossible to compare your own plan to what someone else has.

 

[slo]

Hi there - I posted in red to make it easier....

I am in a FB group for people on a certain, not cheap, medicine. Someone posted that their co-pay went way up this month because they had not met their medical insurance deductible. Their response was that they were going to go off the medicine temporarily until after they had met the deductible.

I was wondering if I am the one who is misunderstanding how this works. Lets say my insurance deductible is $500 doesn't that mean that I have to pay $500 out of pocket and then everything (except co-pays) is covered? Only, if your insurance is 100% after deductible. If your insurance is 80/20 (or 70/30, 50/50 and etc), then you pay 20% until you reach your out of pocket. Once you met your out of pocket, then you pay no copay and everything is 100%. So, how is going off the medication saving them money if they are still paying $500 for other medical services until it is met? This I don't understand, unless it's a medication that isn't a life or death medication. I have a medication that if I stopped it, it wouldn't be the end of the world, but I prefer to stay on it.

Then, last night, my podiatrist office calls me and says that they ran my new shows through insurance and found that I had not met my deductible yet and it was $100, do I still want them to order the shoes? While I do appreciate the heads up, it seemed like I was being asked if I wanted to hold off until I had met my deductible. You probably were being asked that. Many people don't understand how insurance works and would be highly upset to find out they had the $100 balance. I do the same thing at our office when someone needs to order orthotics. I make sure they understand the balance and they give me the go ahead so we don't order the item and then get stuck with it when someone refuses to pay the balance. But if that was the case, I would have to pay $100 for my next medical service anyway. This is true, but many people don't want to start spending money on medical expenses at the beginning of the year unless it's an emergency. We are always slower in January with most everyone's deductible's going back to zero.

Insurance can be so complicated and confusing - I deal with it every day at work, and then I have to deal with my own - LOL!!!

 

[china mom]

To me what doesn't make sense for the person that was going to go off their meds until they met their deductible-- do they really need those meds if they can just stop taking until some time in the future? What are the medical consequences of going off the meds all at once? Could that cause other medical issues that would then cost them more in the long run?

I knoow, That is what makes me so crazy to hear. It is not something that one should just go on and off of.

I feel for people who can't afford medication or care but the tone of that particular post gave me the impression that they could afford it if they had to but were waiting to meet their deductible.

In my case with my shoes, I was given new orthotics and they do not fit in my old shoes so I need new shoes. It is a non issue for me because I can afford shoes but if money were an issue, I wouldn't die or anything by not getting new shoes for another month. But, medication is a whole different situation.

 

[china mom]

Hi there - I posted in red to make it easier....

Insurance can be so complicated and confusing - I deal with it every day at work, and then I have to deal with my own - LOL!!!

OK, Slo, since you mentioned orthotics, I am going to derail my own thread. My orthodics came in and I went to pick them up on Monday and they would not fit in my shoes. Since I was due for insurance to pay for new shoes anyway, they said I should get new shoes - in a bigger size. So, now, I am going to have to walk around in bigger shoes when I already have big feet. But, that is besides the point.

I tried putting my orthotics in DH's shoes just to get an idea of what size shoe I needed and the fit lengthwise but not width. I am starting to think this quack just ordered me canoes and is calling them orthotics.

What happens if these just don't work? Will they be remade at no expense to me? Who eats the cost? Insurance? The podiatrist who molded me? the orthotics guy? or do I jut own a three pair of useless orthotics and have to wait until next year when I am eligible again?

Oh, and I didn't pay a thing for there inserts or the appointment but I owe $100 plus 20% for the shoes if that makes sense.

 

[sam_gordon]

Insurance is driving me batty. We had Open enrollment in August of last year. Part of the guide/presentation had the following:

I think nothing of it, just a different time frame than the normal Jan-Dec. In October, I got checked for a major medical issue (negative). But it was expensive. Paying the bills (which of course didn't come in until December), and I'm $500 from my max OOP.

A different doc wants me to have a different procedure in Jan. Hey, I'm close to my max OOP, so why not? On January 3, I look to see how close I am, and I'm sitting at $0 spent.

The payments reset January 1. I call HR to ask, and they say "Yes, you start paying for the new plan on Sept 1, but it doesn't go into effect until January 1."

Our insurance system is flat out broken.

 

[slo]

OK, Slo, since you mentioned orthotics, I am going to derail my own thread. My orthodics came in and I went to pick them up on Monday and they would not fit in my shoes. Since I was due for insurance to pay for new shoes anyway, they said I should get new shoes - in a bigger size. So, now, I am going to have to walk around in bigger shoes when I already have big feet. But, that is besides the point.

I tried putting my orthotics in DH's shoes just to get an idea of what size shoe I needed and the fit lengthwise but not width. I am starting to think this quack just ordered me canoes and is calling them orthotics.

What happens if these just don't work? Will they be remade at no expense to me? Who eats the cost? Insurance? The podiatrist who molded me? the orthotics guy? or do I jut own a three pair of useless orthotics and have to wait until next year when I am eligible again?

Oh, and I didn't pay a thing for there inserts or the appointment but I owe $100 plus 20% for the shoes if that makes sense.

I have a question........

What did the doctor do for you/to you to determine the type of orthotics you need?

The Chiropractor I work for sells the brand Foot Levelors. He has a scanner that our patients stand on with bare feet, and the scanner scans their feet to the tiniest detail and then the company makes the orthotics from that data. The orthotics come long, and then the patient (or the doctor if the patient would prefer) takes the original insert out of their shoe, matches it up to the orthotic and then cuts the excess off the front/top/toe area so it fits perfectly into their shoe. We've never had a problem with an orthotic not fitting or working well.

In regards to your question on what happens if they don't work - I honestly don't know since I've never had this happen to us. I would imagine that what would happen to us, would be the patient wouldn't pay us, we would call the insurance company to tell them the orthotics weren't accepted by the patient, the doctor would have to reimburse the insurance company the money paid to him, the insurance would debit the patients deductible and the doctor would be out the money he paid to the orthotics company.

Orthotics aren't cheap - if yours don't work, I wouldn't accept them. A good doctor will work with you to make sure you get the right fit to make you feel better.