is anyone health insurance savvy?

[freshstart]

I used to understand my healthcare options inside and out, now no matter how many times I read the definitions of annual deductible, OOP max (how is this different from annual deductible?) and co-insurance I am totally confused. I cannot tell if my Cobra EPO is better than the NYS plans because the plans give very little info and I'm comparing terms that I no longer understand. If anyone can explain those three terms in a simple way, I would be so grateful.

[catherine]

I'm not an expert, but I'll try to answer:

--Annual deductible: the number you have to reach before your benefit kicks in. It's a set number, and it's usually presented both as an individual deductible and family deductible (if applicable)
--OOP max: Aside from paying the deductible there will almost always be other out-of-pocket expenses which is the $$ that the deductible does not encompass: So if, after you reach your deductible, your insurance company covers 70% of the procedures/visits, you pay the 30% out of pocket and that goes toward your OOP max.
--co-insurance: Most people have a set co-payment for office visits (which might be $25 for primary care and $50 for specialists for example). But more and more insurance companies are switching to co-insurance, which means you pay a certain PERCENTAGE, not FLAT AMOUNT. So if you take prescription meds for example, a co-payment means you pay maybe $15 or $30 for a prescription no matter what the price of the prescription is, but co-insurance means you pay a percentage of the prescription, which can be a lot more costly if you have to get expensive meds: a 20% co-insurance on a $1000 medication is $200 OOP.

Hope this helps.

[iris lilies]

Thanks Catherine. I will confess to being perpetually perplexed about how OOP differs from deductibles.

[freshstart]

me too, iris lilies. If you have to reach both, these NYS Marketplace plans sound awful and they all seem to use co-insurance. My Cobra plan is great within my healthcare system but the I can't get what I need sometimes from the bigger medical center. I want to gamble and stick with Cobra but I'm afraid they're going to order more weird tests at the med center. With my luck, I pick a NYS plan to cover that, never get sent to the medical center and i gave up the cheap good insurance. Ugh.

At least they have reps to help you, I go in in 2 weeks. It really helps though, to understand all those terms, thank you Catherine.

[catherine]

It really helps though, to understand all those terms, thank you Catherine.

Keep in mind that the out-of-pocket limit INCLUDES the deductible as well as the portion of bills that is your responsibility/copayment/coinsurances--not sure if I made that clear. And once you hit the max, the insurance company picks up everything.

[freshstart]

but then why do they make the deductible $4500 and the OOP max less? You are saying if you reach the OOP max, you're done, but then you haven't reached the deductible if it's higher, kwim?

I really did get this stuff and even MCR's fabled donut hole when patients needed help with that disaster, my brain just dropped all that knowledge like a hot potato, lol

[rosarugosa]

Freshstart: The OOP max must be more than the deductible, it just doesn't make sense otherwise. Are you insuring yourself only or children too?
My health plan is moving to a $3000 OOP next year (up from $2000), but for purposes of illustration, I'll use my family as an example for this year, where my husband had significant medical expenses, and I had almost none.
Dedt: $600 per person
OOP: $2000 per person
Co-insurance: 20% in network (and we get all our care in network)
Preventative annual physical and related tests: 100% covered
We paid the first $600 of DH's care. Then we paid 20% of his care until we hit $2000 spent out of our pockets (including the $600). Once we hit the $2000, we pay nothing for his care for the rest of the year.
I had an annual physical, and a sickness visit for $133. I paid the $133. because it was less than my deductible, but my plan covered the physical at 100%. Prescriptions are treated separately, and we pay a certain % with no OOP maximum.
That's the way most traditional plans seem to be structured these days. My employer is starting to offer a different type of plan with an HSA. That is structured a bit bit differently and is a bit more confusing. Those plans generally don't benefit people with significant medical costs, so would not probably not be something you would want to choose, given the option.

[freshstart]

Freshstart: The OOP max must be more than the deductible, it just doesn't make sense otherwise. Are you insuring yourself only or children too?


I looked again at the plan I want, I had it wrong. I want to stay with the health insurance company I've had for life, all my docs are on it, I was hoping to find a plan that costs less than Cobra and lets me go to the competing medical center for more in depth tests that I may need. My Cobra plan is through my hospital system so it's actually a good plan, you just have to use their services. That's never been a problem until the past year.

So the plan I found is Bronze level, $540 a month, $4500 deductible and $6500 OOP max. WTH? who can afford that? I'm getting $2900 a month from LTD before tax, but when/if I get SSDI, I have to pay LTD back at $1800 a month. So I really only earn $1100 a month pre-tax that is mine free and clear. But that does not matter and does not make me eligible for help. Although, they said there are tax breaks the Navigator will help me figure out when I meet with them.

At this rate, I think I'm better off with Cobra and just toss the dice on the medical center issue. It's $450, including dental and a decent enough drug plan. Annual deductible is $1250, co-insurance is 20% (I am still shaky on this, like if I hit the OOP max, there's no more co-insurance, right?) and OOP max is $3250.

HR said this year's plan is exactly the same as last year. But I didn't have to reach $1250 before insurance kicked in, right out of the box I just had normal co-pays. I only paid co-insurance on medical equipment. Hit the OOP max by 10/1 so everything has been "free", still pay $450 a month.

the NYS site and application are hard to understand. In my medical system, all of our documents are written at a 5th grade level. You would think those running such a massive site would understand there are lots of people out there who do not understand the above and they would have definitions and explanations. The application was so confusing, I woke up this morning to an email saying my application was accepted when I had left it on hold, half undone.

if I'm a nurse, albeit one whose IQ has dropped a lot, and I can't figure it out, how the heck do all the other people? Thank God they let you meet with someone. That poor sap should run when he sees me coming, lol

[kib]

Don't think it's just you! This probably sounds paranoid, but I am pretty sure this is created/left more complicated than people can untangle on purpose. The fact that this misleading muddle concerns our survival and the largest chunk of our income ... it's not coincidental. >:(

-- I have to admit I'm falling for the same sort of thing. We're on BCBS Federal plan because that's what DH had when I married him, but I found out for the first time last week that there are a whole string of other plans we could choose from, some of which appear to be less expensive, and I basically looked at this three page list of names and dollar amounts with no explanations of the differences in plans and said f*** it, what we have works, I'm not spending a month of life energy reading through this crap only to make the wrong choice anyway. If I can't beat the money thieves, at least I can thwart the time bandits.

[freshstart]

I basically looked at this three page list of names and dollar amounts with no explanations of the differences in plans and said f*** it, what we have works, I'm not spending a month of life energy reading through this crap only to make the wrong choice anyway. If I can't beat the money thieves, at least I can thwart the time bandits.

this is me, screw this. If I make the choice to stay on Cobra and do end up at the medical center for something, I will set up a payment plan with them. Usually if you throw them $50 a month, they're happy. IDK, this may have changed as well, lol

I could choose a different insurer, have to get all new docs who will probably start the whole process of trying to figure everything out all over again. No thanks.

The NYS agent kept saying don't worry about the $6500 OOP max $540 plan because I'll get tax breaks. Think it's highly unlikely they will bring it down to match the Cobra plan.

[Float On]

Isn't Cobra short-termed? I thought it was a plan for in-between insurance and a person could only use it for 18 -36 months depending on the circumstance.

[freshstart]

I get it for 18 mos, started in July so I really do not have to change anything this coming plan year. I kept hearing how low cost the NYS plans are so I am looking into all my options, especially in case I need to go to the bigger medical center.

[Float On]

OK. The couple of times I looked at Cobra it was pretty expensive. Ended up not having to go that route. Health insurance just seems to get more and more messed up.

[Gardnr]

Cobra is short-term. 18months maximum. It is usually VERY expensive. You pick up the entire cost of the plan from your employer.

[iris lilies]

Cobra is short-term. 18months maximum. It is usually VERY expensive. You pick up the entire cost of the plan from your employer.


COBRA coverage lasts longer than 18 months in states that mandate that. I believe CA is one of those states.

We are paying COBRA costs for 18 months and I think the cost is fine, I'm glad to have it.

[bae]

I gave up. I'm only a high energy physicist, statistician, electrical engineer, computer scientist, and firefighter. I delegate the insurance stuff to my wife, the lawyer, because I can't make heads or tails of it.

[sweetana3]

Rant starting.

No one can. Only two things will change it. 1) single payer system or 2) mandating absolutely similiar coverage for everyone from every policy at each level if they still exist so comparability can be absolute.

Wont happen. It is like gambling every year on what your health will be for the next 12 months. What doctors and prescriptions do you think you will need? How the heck would I know unless I was already sick?

I am also really mad about the whole issue of having to give each hospital and doctor who ever sees me a letter that says dont touch me unless you are in my insurance system so I dont get caught with huge bills. So stupid!!!!!!! (ps I have what might be considered a gold or such plan and can still get caught in such messes.)

Rant over.

[pinkytoe]

I have tried but I still don't understand much about my BCBS PPO coverage. All I know is that I recently visited three different doctors (4x) for a health condition (office visits and basic lab tests) for a total of $7500 billed to insurance. I am only out for the $30 co-pays on each visit. For all four visits, I received a prescription, none of which I ending up filling but they would have all been at no cost. Ironically, the condition resolved on its own and cemented my belief to stay away from docs in most cases.

[freshstart]

my former employer HR director emailed me back exactly how the terms I did not understand would work in various scenarios. As long as I stay away from the medical center, I end up paying about half with my EPO Cobra than with the bronze NYS plan with the same insurance company (it would not be good for me to change horses with my team of doctors right now, it took almost a year to get everyone really working together and I do not want to start that all over). I think I'm gonna gamble and stick with what I know, but I will keep the appointment with the NYS Marketplace guy just in case. The best part of my EPO, is I have an annual deductible but it does not kick in for MD appts, meds, etc. You only have to meet it with hospitalizations out of the network and very expensive tests. The NYS Marketplace one is $4500 before anything gets paid and $540 a month.

I think the people getting "great" plans for $200 a month are very healthy and have not had to deal with a medical crisis yet on their plan. I could be wrong, who knows. x