Please answer a silly question for me

[frugalone]

I just want someone to confirm if I am right or wrong here.

Let's say I have a $4K deductible with my health insurance. And that I get bitten by a dog, and I have an ER bill of $5,000. A $4K deductible means that the insurance will not kick in until I have paid $4,000 toward the $5,000. Then the insurer will pay the other $1,000.

Am I right?

[catherine]

You're mostly right, but it depends on what your co-insurance is. Your insurance might only pay 70% or 80% of the $1000 after the deductible is met.

[CathyA]

Also.......what you are charged depends on the relationship the medical place has with your insurance. And also.........sometimes you might have a bill for a certain amount, and the insurance company might only consider a portion of that amount deductible. When all is said and done, if you've actually paid out $4,000..........then everything else should be paid for by the insurance co.UNTIL the new year. (If that's what your policy says). Then the craziness starts all over.

[rosarugosa]

Catherine is correct. You usually have to pay some percentage of the amount over your deductible. 20% of that additional $1000 would be common. Some plans also have an out of pocket maximum, and after you meet that, you don't pay anything. Presecription are often excluded from the OOP maximum though, so you would still keep paying for those.

[frugalone]

Oh dear...this is more complicated than I thought. Not black-and-white.
Thanks, guys.

[frugalone]

Oh dear...this is more complicated than I thought. Not black-and-white.
Thanks, guys.

[CathyA]

Frugalone.......can you write all your questions out and call your insurance people? Everyone's insurance can be very different.......so I say give them a call and ask them all your questions.

[Simpler at Fifty]

It might be good to look at your insurance policy too. It is easier to understand than you might think. Especially based on the advice you have received above. If you follow CathyA's advice and call your insurance company, find the ER benefits in your policy so you can follow along as they are explaining it. Write down the date and time you called and who you spoke with and what was said. Then you can review back to that documentation when you get your eob (explanation of benefits) from the insurance.

[ApatheticNoMore]

Presecription are often excluded from the OOP maximum though, so you would still keep paying for those.

that fine sounds better and better by the day. Because what I hear is I'm paying between 3-4k a year (not even counting the employer part which brings the cost to 7-8k a year) for a policy that's I can't rely on anyway. And the ONLY reason I buy the stupid policy is for bankruptcy protection in case of health problems - I frankly could care less whether they pay routine doctor visits. And if it's not good for bankruptcy protection then what exactly is it good for? The only reason I got this overpriced policy is I thought it had hard out of pocket maximums, in and out of network, for everything. It's not like I'm getting my money's worth otherwise.

[Spartana]

You're mostly right, but it depends on what your co-insurance is. Your insurance might only pay 70% or 80% of the $1000 after the deductible is met.

Also some of the bronze level ACA plans only cover 60% of after-deductible costs( and those deductibles seem to be in the $6,000 to $7000 range) and the policy holder has to pay the additional 40% co-insurance. Monthly premiums range from $219 - $250 or so for bronze and about $100/month more for silver. The silver and gold plans also have $6k plus deductibles but they cover 70 and 80 percent of costs afterwards. Platium plans have approx $4k deductible and cover 90% afterwards but their premiums are much higher. Thats's according to the California Covered exchange website. I downloaded all that info. I'm sure there are differences between insurance companies as well as in other states. And of course if you qualify for subsidies your premiums will be less but you'll still have to psy for you deductibles, co pays and co insurance.

I believe that the OP, like me, has had their current policy cancelled as of Jan 1 and is looking at buying a new policy on the exchanges so may not have an agent to talk to directly. I've been trying to e mail and call insurance comanies outside of using the exchange to talk about policies, and am having difficulty.

[Gardenarian]

I have another stupid question - is the deductible per incident, or per year?
Say, a month after I got bit by the dog, I fell down the stairs. Would I have a $5000 deductible for treatment of that?
I know every policy is different, but usually - is the deductible annual?

[Spartana]

Deductibles are per year not per incident. I believe deductibles are per calander year beginning every Jan 1st. So I believe if you were bit on Jan 1st of a new year you'd have to pay the full deductible anew even if you had it already paid for your previous years dedctible on Dec 31st.

Also I don't think deductibles are pro-rated from the date you bought insurance until the end of the year. So if you bought a new policy in June rather than Jan, you still have to meet the full years deductible before the insurance company begins paying.

[Simpler at Fifty]

What Spartana said is correct. Your deductible typically is calendar year (1/1/year), fiscal year (7/1/year) or plan year (in my case it is also 7/1/year) Most of the time the ded is not carried over to the next year. Years ago many plans had a 'carry over credit' provision. So if you were on a calendar year plan and on Nov 1 of that year you met your ded, that amount carried over to the next calendar year. Those plans were offered mostly by large employers back in the 250 ded 90/10 coinsurance days.

[Gardenarian]

Thanks, you smart people!

[Spartana]

I also have a question. I know that your monthly premiums and co-insurance (that per cent of costs youust pay beyond what your insurance company covers for services) doesn't go towards reducing your annual deductible amount but what about co-pays? That upfront fee you must pay to a provider. Does that amount go towards your annual deduction? Some of the bronze level plans I looked at have hefty co-payments in addition to deductibles and co-insurance. Gotta admit it's all confusing to me.

[frugalone]

Spartana is correct: I got one of those letters cancelling my current plan because it no longer meets the government's minimum requirements for health care.
I called the insurer and they said to look at the Silver Plans. The deductible looks pretty high. I still have to go on the exchanges and see if I am eligible for a subsidy.