Help me to understand insurance and birth medical bills. What am I missing?

posted 1 year ago in Wellness
Post # 16
Member
1098 posts
Bumble bee

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teamroro :  Unfortunately, I have a high premium and a high deductible plan THROUGH MY EMPLOYER! Totally nuts. I have an HSA that I use to help save money pre-tax. But I had to have major surgery last year and between my premiums and my out of pocket expenses, I was well over $10k.  

Post # 17
Member
1536 posts
Bumble bee

You have a deductible and co-insurance.  First you have to meet your deductible, which is separate from the monthly payment.  Then you pay your co-insurance until you meet the max out of pocket.  This is typically 20-30%.

You have the monthly premium of $1000

say your deductible is $5000. So you pay all bills until you hit that

Co-insurance is a percentage until you hit the max out of pocket.  Buying on the open market through a business is typically $7500 or $10,000 for a family.

This is just an example but you need to look at your health card and it will tell you.  Call your insurance company and see what you can do.

Post # 18
Member
25 posts
Newbee

Another thing to check out is your out of pocket maximum. That is the most that you should have to pay during your plan year. You may have a per person out of pocket max and a family out of pocket max. 

For example, lets say  your deductible is 3500, but the out of pocket max is 10000. After you’ve paid the 10000 (which doesn’t include your premiums) everything for the rest of your plan year is free. Last year my husband had 3 surgeries so we got to our out of pocket max for him. So the rest of the year we definitely worked it (got him a new cpap, refilled all maintenance prescriptions, etc) without having to pay for anything other than the premium. 

So, good luck. If you haven’t already, be sure to work out a payment plan with the hospital. 

Post # 19
Member
2181 posts
Buzzing bee

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mrscb2bee :  You’ll want to look at a few things to see if you’re being billed the right amount. First, look for your policy statements to see what your deductible is per individual and family as well as your out of pocket maximum (also individual and family). Most likely, your birth maxed out your individual out of pocket maximum, but your son will have to maximize his as well. Your insurance company should be able to tell you how much of each deductible and out of pocket has been met so far this year.

The other thing to do is look at your EOB which you can get from your insurance company, and make sure the amounts on those match your bills from the hospital. They should be the same, but errors can be made or there can be services that weren’t covered by insurance that may require an appeal process.

But from the amounts you listed, no, I don’t think you were overcharged. Medical care is expensive.

Post # 20
Member
569 posts
Busy bee
  • Wedding: June 2017

Agree with everyone else. Verify your deductible and OOP max. Most insurance companies these days have pretty good visuals on their website so you can track. And of course, when in doubt, call the hospital or your insurance company. Also- I’m a hospital administrator- most hospitals will give you a discount if you can pay in full or work with you on a reasonable payment plan. Good luck! 

Post # 21
Member
5402 posts
Bee Keeper

If your deductible is $3500 and you’re paying $5000 I’d double check every bill with your insurance company.  After the deductible is met you should have some sort of discount or benefit.  Pharmaceutical is usually separate from the general deductible and sometimes there is a separate hospital deductible.

So I’d ask how much is my deductible (even though you know get them to explain it). Then ask is that my only deductible. Then ask what is my percent owed after deductible is met? Then ask if you have coinsurance.  That is another confusing af thing that could effect the bill. 

Ask the hospital to tell you what billing codes they used. Sometimes they used an inappropriate billing code.  This will help when you ask the insurance what is covered for xyz code. 

Sometimes they don’t bill everything through insurance like they should. Happened to me with my braces post surgery. So make sure it was actuslly billed to insurance.

How do I know this? Yearsssss of desling with insurance  billings for myself. 

Post # 22
Member
7573 posts
Bumble Beekeeper

Sadly this sounds normal to me. You have a pretty shit plan (welcome to USA), but even with those high premiums and high deductible, you’re still paying a lot less than you’d be paying for the birth without any plan. I agree with pp re: checking your out of pocket max. Hopefully, you’ve hit that now, which, if so, means time to schedule endless appts for the rest of the year for everything you can think of!

Post # 23
Member
2499 posts
Buzzing bee
  • Wedding: September 2018

Take the time to learn about your health insurance plan. You know your deductible, but what is your out of pocket max? What happens after you meet your deductible – do you have coinsurance? copays? A lot of times things can get billed incorrectly due to human error, so it’s your responsiblity as a consumer of healthcare to learn about your plan and be your own advocate. 

Post # 24
Member
387 posts
Helper bee
  • Wedding: City, State

Unfortunately I think that is all pretty accurate, If your deductible is $3500, then your out of pocket maximum is likely $7000. For the first $3500, you pay 100% of the costs your insurance company negotiates (lower than the actual hospital billing). After that amount, its usually an 80/20 where you pay 20% of the costs and the insurance pays 80% until you reach your out of pocket maximum for that calendar year. As others have said, you need to familiarize yourself with this amount so you know what to expect in the future. This maximum has absolutely nothing to do with the premium you pay monthly. 

This is sadly the new state of US health care after all of the Obama Care changes years ago. Legally they can’t deny you anymore, but the costs have become outrageous. Just be thankful it doesn’t span a calendar year (saw a PP say they gave birth in December and hospital stay went over to January – that is when you really get screwed and have two years of out of pocket maximums!) 

Post # 25
Member
1390 posts
Bumble bee
  • Wedding: September 2011

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mrscb2bee :  Basically, you’re paying $1k per month just to have insurance (this does not go toward any of your personal costs–it goes to the insurance company who will start paying after you have spent your deductible) and your co-insurance does not kick in until you hit your deductible of $3500–so until you spend $3.5k on medical costs for the year. Then during your co-insurance you pay a percentage of your insurance until you hit your out of pocket maximum.

Throwing some random numbers out there to make this more clear–assume that Person X has a $3.5k deductible. And that once the co-insurance kicks in for person X, maybe they cover 80% of the bill and Person X is responsible for 20%. That means that after Person X pays $3500 in medical costs, they are still responsible for 20% of the bill (and insurance picks up 80%) until they hit their out of pocket maximum. And of course if their insurance doesn’t cover something, then they are responsible for it. Does that make more sense now?

I have no idea what your specifics are, but it looks to me like you are paying a very high premium with a high deductible. From your post, it looks like you didn’t realize that the premium is for the privilege of having insurance. You can’t change things now, and you’re still saving $ from the $46,000 you would have been responsible for if you didn’t have insurance, but I would look into different health insurance options in the future.

Post # 26
Member
1390 posts
Bumble bee
  • Wedding: September 2011

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temeculabride :  “This is sadly the new state of US health care after all of the Obama Care changes years ago. Legally they can’t deny you anymore, but the costs have become outrageous.”

Not entirely true, premiums increased after the ACA rolled out but overall out of pocket costs went down. Is the ACA perfect? No it’s definitely not, but at the same time getting more people insured was a start. Otherwise you’d have people who are uninsured getting absolutely screwed over by healthcare costs, which has been a huge problem. Plus, people with “pre-exisiting conditions” were sometimes uninsurable, so even if they wanted health insurance they couldn’t have it. Don’t get me wrong, I don’t think the current system is perfect or even good, but it’s a start. IMO health insurance is necessary for everyone and should become a non-profit endeavour. Single payer is one way to get there.

Post # 27
Member
172 posts
Blushing bee
  • Wedding: November 2020 - North Carolina

You may have already tried this but you might be able to apply for Medicaid for Pregnant Women in your state. IDK if they offer this in your state or not but it’s basically Medicaid for women who are pregnant even though they may not have qualified for Medicaid otherwise. You can apply even if you already have insurance through somewhere else. It’ll just act as your secondary insurance. If you do decide to go this route you need to act fast because Medicaid will cover any bills up to 3 months prior to you applying. It might not cover everything but it could help soften the blow.

Post # 28
Member
722 posts
Busy bee
  • Wedding: January 2021 - Dracut, Massachusetts

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LilliV :  Just wanted to say the same as a Mass resident too and it grosses me out what other people pay. Although, I work for a hospital so like, I get better coverage than most companies anyway. You know what’s sad? The previous company I worked for, I paid $160 a month for a 2k deductible. Then I purchased from the marketplace when I was per diem at MGH and I paid the same for NO deductive. How crazy is that?!

Post # 29
Member
5563 posts
Bee Keeper
  • Wedding: October 2017

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blondie603 :  I work for a hospital too, last year we had no deductibles or coinsurance, we were so unbelievably spoiled and we didn’t realize until the plans switched this year. Our insurance is still amazing but now we have deductibles and coinsurance, it’s an expense that we haven’t had to worry about before.

It’s a big expense for hospital stays, I thought our first experience would be the birth of our second child (we haven’t start ttc yet). Then my husband had a heart attack, so I’m right in the thick of it

Post # 30
Member
2037 posts
Buzzing bee
  • Wedding: May 2016 - Sussex, UK

UK bee so nothing to add other than aside from MH services I’m hugely grateful for our NHS. I guess salaries are comparatively higher in the US so maybe it doesn’t feel as big of an expense as it sounds 

OP, I hope you soon work out what you definitely do or don’t owe.

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