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Comment on How exactly do insurance deductibles work?

ChaosCoati@midwest.social ⁨3⁩ ⁨months⁩ ago

You need to know both your deductible and out of pocket maximum numbers. You’ve said your deductible is $1500. For the sake of this example let’s say your out of pocket max (OOP from now on) is $2500.

For simplicity, we’ll go with your insurance’s negotiated rate for the procedure is $1000*. Meaning at the end of the day you and your insurance combined will pay the hospital $1000.

Basically any bills up to $1500 for the year you pay 100%. Between $1500 and $2500 (or your OOP), insurance pays 50% and you pay 50%. Over $2500 insurance pays 100%.

Some examples to illustrate:

You’ve paid $400 this year so far. You pay the full $1000: $400 + $1000 = $1400 which is less than your deductible of $1500
You’ve paid $1000 so far this year. You pay $750 and insurance pays $250: $500 gets you to the $1500 deductible limit so you have to pay all that, plus you pay 50% of the remaining $500 bill = $250.
You’ve paid $1700 so far. You pay $500 and insurance pays $500. $1700 + $500 = $2200 which is less than your OOP of $2500
You’ve paid $2300 so far. You pay $200 and insurance pays $800. 50% of $1000 = $500 but $500 would put you over your OOP of $2500. $2500 - $2300 = $200. You pay $200 and insurance pays the rest.
You’ve paid $2500 so far. Insurance pays $1000

If your insurance’s negotiated rate for the procedure is $1000, this means that’s what the hospital and insurance have agreed to pay. A lot of times you’ll see the hospital “charge” a larger number and then have an insurance “discount” but ignore this. It doesn’t factor into deductible or out of pocket maximum calculations.

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ALostInquirer@lemm.ee ⁨3⁩ ⁨months⁩ ago
Why is this all so convoluted and, seemingly, legal? Is this purposely convoluted to obfuscate illegal activity?

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- ChaosCoati@midwest.social ⁨3⁩ ⁨months⁩ ago
  I don’t know the actual answer. My theory is it’s this confusing so it’s hard for the general population to catch the mistakes. This allows insurance companies get out of paying as much as they’re supposed to. And hospitals don’t really care who does the paying, as long as they get paid
  
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GlendatheGayWitch@lemmy.world ⁨3⁩ ⁨months⁩ ago
Don’t forget, insurance covers 50% before the deductible is met, not after. When a policy has that verbiage, usually there’s a footnote that states how those claims are handled in the future. From what I’ve seen, that could mean that insurance will cover 100% of said procedure after the deductible is met or it could mean a co-insurance of 30%.

After the deductible is met, OP won’t necessarily pay 50%. The percentage of the bill that OP and/or insurance will pay will be on a footnote at the bottom of the blue plan overview page (at least it’s blue when looking at plans from the ACA marketplace).

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xmunk@sh.itjust.works ⁨3⁩ ⁨months⁩ ago
For bonus points let’s also assume that the user is 2100 away from their lifetime cap in scenario three: then instead pf you and your insurer splitting the 1k bill evenly your insurer would split 800 with you (400 from each of you) before saying “peace bro im out” and leaving you with the remaining 200 dollar bill.

Additionally the user above was assuming that insurance would cover half the bill - that’s actually a variable that your personal plan might disagree with called your “coinsurance” rate, you could have a 50% coinsurance rate, an 80% rate (an awful plan) or a 0% rate which would mean you’re fully covered after you hit your deductible (assuming there aren’t any annual coverage cap shenanigans).

Also fun is out of network stuff, different plans may vary but let’s take scenario three again but assume the HCP you went to was out of network and their charge master (see parent’s footnote) says the actual raw cost of the procedure is 23,000 dollars. Your insurer might handle this in two ways:

“get fucked” - your insurer offers no coverage at all for out of network charges - in this case the 23k bill goes against your bank account directly and you likely end up declaring bankruptcy or delinquenting on the loan.

“get (slightly less) fucked” - your insurer looks at what you would have paid at an in network HCP and partially pays for your procedure assuming you had it done at an approved HCP. In this case your insurance pays 500 and you just need to cover the remaining 22.5k… so you once again may consider bankruptcy.

In both cases, for shits and giggles, this extreme medical cost does not count toward your OOP - except for 1000$ in the second case if partial coverage is awarded. This is why people Uber to specific hospitals after traumatic injuries.
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- ChaosCoati@midwest.social ⁨3⁩ ⁨months⁩ ago
  All very valid points and part of why American health insurance is such a joke
  
  I had an incident recently where my spouse had to go to the ER because of a life threatening incident. One of those fix it right now or they might die things. (They’re fine now, thank goodness.)
  
  We went to an in-network hospital and all doctors were also in-network. However the one who actually did the life-saving procedure was a specialist. Under our insurance plan seeing a specialist requires a referral, which of course we didn’t have time to get. So insurance tried to nope out of that doctor’s entire bill.
  
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