Posted: 9/11/2015 7:56:05 AM EDT
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Hello, I was hoping for some clarification. I have health insurance through my employer. My "maximum out of pocket" is $1,700. My wife's is $1,700 as well. But our "Family out of pocket" is $4,500.
1) Where does the $4,500 come in? If my wife and I reach our maximums we are only at $3,400 and we have no one else on our plan. 2) I currently pay 10%. The plan pays 90%. I have a recent $57,000 hospital bill that is still pending. (Scheduled surgery to correct a chronic knee issue) When I reach my $1,700 maximum am I completely done paying anything for my plan's year? Thanks. |
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Quoted:
Hello, I was hoping for some clarification. I have health insurance through my employer. My "maximum out of pocket" is $1,700. My wife's is $1,700 as well. But our "Family out of pocket" is $4,500. 1) Where does the $4,500 come in? If my wife and I reach our maximums we are only at $3,400 and we have no one else on our plan. 2) I currently pay 10%. The plan pays 90%. I have a recent $57,000 hospital bill that is still pending. (Scheduled surgery to correct a chronic knee issue) When I reach my $1,700 maximum am I completely done paying anything for my plan's year? Thanks. 1. If you and your wife are the only ones on the plan, then only the $1700 each matters. There is no "Family". Family means kids. 2. Your insurance company will negotiate with the hospital and likely reduce the $57K bill. You will be responsible for 10% of the final amount. If your out of pocket expenses exceed $1700, then insurance pays 100% for the rest of the year. You might still have to make co-pays for office visits and prescriptions. |
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Quoted:
1. If you and your wife are the only ones on the plan, then only the $1700 each matters. There is no "Family". Family means kids. 2. Your insurance company will negotiate with the hospital and likely reduce the $57K bill. You will be responsible for 10% of the final amount. If your out of pocket expenses exceed $1700, then insurance pays 100% for the rest of the year. You might still have to make co-pays for office visits and prescriptions. Quoted:
Quoted:
Hello, I was hoping for some clarification. I have health insurance through my employer. My "maximum out of pocket" is $1,700. My wife's is $1,700 as well. But our "Family out of pocket" is $4,500. 1) Where does the $4,500 come in? If my wife and I reach our maximums we are only at $3,400 and we have no one else on our plan. 2) I currently pay 10%. The plan pays 90%. I have a recent $57,000 hospital bill that is still pending. (Scheduled surgery to correct a chronic knee issue) When I reach my $1,700 maximum am I completely done paying anything for my plan's year? Thanks. 1. If you and your wife are the only ones on the plan, then only the $1700 each matters. There is no "Family". Family means kids. 2. Your insurance company will negotiate with the hospital and likely reduce the $57K bill. You will be responsible for 10% of the final amount. If your out of pocket expenses exceed $1700, then insurance pays 100% for the rest of the year. You might still have to make co-pays for office visits and prescriptions. More like he will cover 10% of the $57K (up to your max contribution) and the insurance company will negotiate down their part of the bill |
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More like he will cover 10% of the $57K (up to your max contribution) and the insurance company will negotiate down their part of the bill That's not the way it usually works. The insurance "negotiation" (actually, they have a set schedule of fees that providers agree to ahead of time) applies to the full amount before the copayment is figured. This is the great advantage of having insurance. Even if you have to pay 100% (because of not having satisfied your deductible, for example), you are paying 100% of a reduced amount. The only people that pay the full freight (which is artificially inflated, btw) are those without insurance but having enough money so that Medicaid, etc., does not kick in. |
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Quoted:
That's not the way it usually works. The insurance "negotiation" (actually, they have a set schedule of fees that providers agree to ahead of time) applies to the full amount before the copayment is figured. This is the great advantage of having insurance. Even if you have to pay 100% (because of not having satisfied your deductible, for example), you are paying 100% of a reduced amount. The only people that pay the full freight (which is artificially inflated, btw) are those without insurance but having enough money so that Medicaid, etc., does not kick in. Quoted:
More like he will cover 10% of the $57K (up to your max contribution) and the insurance company will negotiate down their part of the bill That's not the way it usually works. The insurance "negotiation" (actually, they have a set schedule of fees that providers agree to ahead of time) applies to the full amount before the copayment is figured. This is the great advantage of having insurance. Even if you have to pay 100% (because of not having satisfied your deductible, for example), you are paying 100% of a reduced amount. The only people that pay the full freight (which is artificially inflated, btw) are those without insurance but having enough money so that Medicaid, etc., does not kick in. This is how it ended up working. Original bill was $57,000, the "negotiated" amount was $7,200. I owed money on the $7,200, not the $57,000. Moot point for me, as by the time the Docs and pre-op appointments were paid for I only had $650 left to reach my out of pocket maximum. If I owed 10% of 57k or 7k it'd still be the same amount out of my pocket but if my out of pocket maximum was higher it's a very good thing they do 10% of the negotiated amount. Why bill $57,000 and accept $7,200? What purpose does that serve? |
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Why bill $57,000 and accept $7,200? What purpose does that serve? It's all gamesmanship. Insured people that suddenly find their bills reduced to a fraction of the original amount get a good feeling about their insurance. (That "reduced" or "negotiated" amount is probably actually close to the provider's true cost.) So both the insurers and the providers win. The "inflated" amount ($57,000 in this case) is actually paid by hardly anyone. The main category of people who would be stuck with that would be those who (a) did not have insurance, and (b) were well-off enough so that the providers could collect from them. (Remember, though, that uninsured medical bills are one of the leading causes of bankruptcy. If the patient goes bankrupt, the provider still doesn't collect.) |