BlueCross BlueShield Coinsurance Help

[GlockSpock]

Recently at work our insurance changed from a "co-pay" system to "coinsurance". Well, frankly everything to do with health insurance confuses me more than a hippie at an NRA convention.

 

Long story short, I took my wife to a local doctor today. Nothing too serious, just wanted a diagnosis. However, this was the first time that we have "tested" the new insurance. My understanding (after leaving our insurance meeting), was that the coinsurance kicked in until you met the maximum out of pocket amount. For example, if the negotiated rate is $100 for an office visit, you'd be responsible for 20% of that. However, if you've met your maximum out of pocket amount, then you don't have to pay anything. That is what I understood.

 

I was billed $95 today and had to pay upfront because they checked my deductible and saw that I had not met it for this "year". She described to me that the coinsurance kicks in after you meet your deductible. Perhaps she is right, but this isn't at all what I understood after the initial insurance meeting at work. I just don't think this is the case.

 

Something that is confusing me here is the interchangeability of the words "deductible" and "maximum out of pocket". Are they the same? Are they different? How do they relate to each other if they are different?

 

I know this is a lot of stuff to know about, and ultimately I will be checking into it tomorrow as soon as I can. However, I would like some input from the fine folks here at TGO if you feel qualified to give some.

 

Here is the "policy" I suppose that we have:

https://dl.dropboxusercontent.com/u/120877/Policy.pdf

 

 

[Glenn]

I a not an insurance expert but have made extensive use of BCBS insurance. Deductible means you pay it all, or at least the insurance company's negotiated price, until you have met your deductible. Some types of tests and visits are not subject to the deductible, and non covered charges don' t count towards your deductible. Once you have met your deductible you pay 20% coinsurance untill you have spent your out of pocket amount, then BC pays 100%, except for non covered expenses which you still have to pay. Clear as mud, huh!

[GlockSpock]

I a not an insurance expert but have made extensive use of BCBS insurance. Deductible means you pay it all, or at least the insurance company's negotiated price, until you have met your deductible. Some types of tests and visits are not subject to the deductible, and non covered charges don' t count towards your deductible. Once you have met your deductible you pay 20% coinsurance untill you have spent your out of pocket amount, then BC pays 100%, except for non covered expenses which you still have to pay. Clear as mud, huh!

 

So in my scenario, my deductible is $2,500 ($5,000 family) and the out-of-pocket-limit is the same. Is this essentially saying that I will pay 100% of office visits/surgeries up until that limit, and then what? I still don't see where the coinsurance comes in, because with the deductible and out-of-pocket-limit being the same, it doesn't make sense.

[Oh Shoot]

I a not an insurance expert but have made extensive use of BCBS insurance. Deductible means you pay it all, or at least the insurance company's negotiated price, until you have met your deductible. Some types of tests and visits are not subject to the deductible, and non covered charges don' t count towards your deductible. Once you have met your deductible you pay 20% coinsurance untill you have spent your out of pocket amount, then BC pays 100%, except for non covered expenses which you still have to pay. Clear as mud, huh!

 

Yep, that's about it. Deductible must be met first with any plan, even straight Medicare.

 

Some plans even with a flat rate co-pay also have a yearly deductible up front.

 

It's important to know if the term of the plan is calendar year or year based on when plan was enacted, you wouldn't want to lay out significant bucks a month or two before year starts over if you can avoid it, especially for a condition you expect to have to periodically deal with repeatedly.

 

- OS

Edited August 4, 2013 by Oh Shoot

[Oh Shoot]

So in my scenario, my deductible is $2,500 ($5,000 family) and the out-of-pocket-limit is the same. Is this essentially saying that I will pay 100% of office visits/surgeries up until that limit, and then what? I still don't see where the coinsurance comes in, because with the deductible and out-of-pocket-limit being the same, it doesn't make sense.

 

That really doesn't sound right, never heard of a plan where yearly out of pocket wasn't more than the deductible. Then again, lots of changes over last few years, couldn't say.

 

- OS

Edited August 4, 2013 by Oh Shoot

[Sam1]

I a not an insurance expert but have made extensive use of BCBS insurance. Deductible means you pay it all, or at least the insurance company's negotiated price, until you have met your deductible. Some types of tests and visits are not subject to the deductible, and non covered charges don' t count towards your deductible. Once you have met your deductible you pay 20% coinsurance untill you have spent your out of pocket amount, then BC pays 100%, except for non covered expenses which you still have to pay. Clear as mud, huh!

 

Glenn has it there, I've dealt with around $700k of medical bills through BCBS and that's what happens - 

 

The standard plan with BCBS is a straight ripoff - it costs more to have it, then you have deductibles on top of your copayment.  The basic plan looks like a few bucks more per visit (say $25 copay instead of $20), but it's actually cheaper because you have no deductible.

 

So for example if you have the standard plan and go have a physical that has a copayment of $20, but since you haven't met the maximum deductible amount this year, you may get charged an additional $175 for whatever services involved in the physical. This visit that just cost you $195 with the standard plan, would've only cost you a $25 copayment with the basic plan.  On top of that, you are already saving $100+ per month on the plan costs by having the basic.

 

None of this has to do with the catastrophic loss though, these are $7k in out of pocket expenses for a family (with my BCBS) before they pay 100%.  

[Sam1]

So in my scenario, my deductible is $2,500 ($5,000 family) and the out-of-pocket-limit is the same. Is this essentially saying that I will pay 100% of office visits/surgeries up until that limit, and then what? I still don't see where the coinsurance comes in, because with the deductible and out-of-pocket-limit being the same, it doesn't make sense.

 

As OS said, sounds strange... do you have a link to your benefits brochure online by chance?

[GlockSpock]

Well...I linked to what I am going by in the OP; Here it is:

 

https://dl.dropboxusercontent.com/u/120877/Policy.pdf

Edited August 4, 2013 by CZ9MM

[Sam1]

Holy smokes man! I hope to goodness that is not in store for everyone, I've never seen a deductible at the same level as a catastrophic limit. - although with all my medical issues, that would save me a few grand every year.

 

Here's a link to how they "normally" work:  http://www.fepblue.org/benefitplans/standard-option/medical-benefits.jsp#physicians-care

 

If you look on there, there's a copay, then you pay whatever % of the plan allowance (negotiated price the doctor can charge you under BCBS contract) up until it reaches $350 for the year 

 

 

 

Calendar Year Deductible = One $350 deductible per member per calendar year, $700 family limit each calendar year. Certain deductibles and coinsurance amounts do not apply to you if Medicare is your primary coverage for medical services (it pays first).

 

After the $350 limit is reached, you have the copays only until the catastrophic limit is reached (for this specific plan $5000). 

 

I'm still amazed your deductibles go to $2500 which is the catastrophic limit, that's going to end up costing people a metric ton more of money unless you've just got a bunch of issues and normally run above $2000 in medical bills every year.  I would suggest whenever your open enrollment happens that you re-evaluate the plans available very closely with a coworker or someone from your HR department to see if there's a better option.

 

* to add, if you have access to the BCBS basic plan with no deductibles, give that a good look over but DO NOT just go off my word, every company's plans are different  and they will differ from what anyone else has experience with.

Edited August 5, 2013 by Sam1

[Guest sL1k]

My insurance is the same as no insurance . I have to pay 1700 out of pocket before they pay a dime then I have to pay 20 percent up To 3k before they pay 100 percent. I pay $15 a week for that lovely coverage. If I had a family I would have to pay $3500.
I do have a health savings account.

I've never heard of coinsurance though.

[jcj]

My insurance is the same as no insurance . I have to pay 1700 out of pocket before they pay a dime then I have to pay 20 percent up To 3k before they pay 100 percent. I pay $15 a week for that lovely coverage. If I had a family I would have to pay $3500.
I do have a health savings account.

I've never heard of coinsurance though.

I feel your pain. $3,000 deductible then insurance pays 90% after that. I deposit 3K/yr out of my paycheck into the HSA on top of what I pay for the plan premium.

Sent from my SPH-L720 using Tapatalk 2

[GlockSpock]

Holy smokes man! I hope to goodness that is not in store for everyone, I've never seen a deductible at the same level as a catastrophic limit. - although with all my medical issues, that would save me a few grand every year.

 

Here's a link to how they "normally" work:  http://www.fepblue.org/benefitplans/standard-option/medical-benefits.jsp#physicians-care

 

If you look on there, there's a copay, then you pay whatever % of the plan allowance (negotiated price the doctor can charge you under BCBS contract) up until it reaches $350 for the year 

 

 

After the $350 limit is reached, you have the copays only until the catastrophic limit is reached (for this specific plan $5000). 

 

I'm still amazed your deductibles go to $2500 which is the catastrophic limit, that's going to end up costing people a metric ton more of money unless you've just got a bunch of issues and normally run above $2000 in medical bills every year.  I would suggest whenever your open enrollment happens that you re-evaluate the plans available very closely with a coworker or someone from your HR department to see if there's a better option.

 

* to add, if you have access to the BCBS basic plan with no deductibles, give that a good look over but DO NOT just go off my word, every company's plans are different  and they will differ from what anyone else has experience with.

 

What frustrates me beyond belief is that we were (unless I just misunderstood it all completely) that we paid the coinsurance rate up to the maximum out of pocket, then we were responsible for nothing. The sad thing is that the plan we were on a just until July 31st was a decent plan with a $30 copay and decent deductibles. It just seems so *nonfunctioning and doesn't even seem to make sense to me that your deductible and out of pocket maximum would be the same. I still don't see *exactly where the coinsurance would come into play.

[Oh Shoot]

My insurance is the same as no insurance . I have to pay 1700 out of pocket before they pay a dime then I have to pay 20 percent up To 3k before they pay 100 percent. I pay $15 a week for that lovely coverage. If I had a family I would have to pay $3500.

 

Try carrying Cobra to keep a group policy going for about 7 or 8 years and then get individual insurance at the age of 55. Yours would be a very good deal indeed.

 

I've lived with 5K deductible, 50/50 to $7500 max out of pocket, no copay or coinsurance,  for about 8 years now until I recently turned 65. Premium was up to $535 a month when I went on Medicare last month.

 

They never had to pay a dime, since I never had a serious issue. The only thing paying over $6K a year got me was that I was charged the contracted insurance rate for services, rather than the uninsured rate. As I'm sure yours does too, so it's really not at all "same as no insurance".

 

Medicare (using freebie Blue Cross Advantage Plan) saves me over $5k a year right off the bat, not to mention free gym membership, which is another $600 just at the YMCA, plus all services are much cheaper than the private insurance rate, $20 doc/$40 specialist, etc.

 

I'm actually looking into having my elbow fixed, could never afford it before, looks like MRI and surgery will cost me under 500 clams plus another 100 or so for follow up specialist visits.

 

And I sure appreciate you all chipping in for it!

 

- OS

Edited August 5, 2013 by Oh Shoot

[Oh Shoot]

Well...I linked to what I am going by in the OP; Here it is:

 

https://dl.dropboxusercontent.com/u/120877/Policy.pdf

 

Well, good news is that not a bad out of pocket expense level at all if serious bad things happen, but a bit rough the wallet for normal health care until you hit it. The 20% coinsurance is pretty much same as $20 doctor visit and $30-40 specialist visit, though, as they'll be charging the contracted insurance rate rather than the "off the street" max, and is pretty much in line with most "co-pay" policies nowadays AFAIK.

 

Re-read my post just above to make you feel better overall.

 

Anyway, I suppose it's a group plan that you had no options regarding premiums vs options?

 

- OS

Edited August 5, 2013 by Oh Shoot

[Guest 6.8 AR]

Do you have two separate policies that your coverage can be paid from? If there are different policies that can

be responsible, like you having a primary on yourself, through say Blue Cross, and your wife, through say Aetna,

I think that would cause a co-pay situation, along with a coinsurance situation.

 

Medicare and the supplements cause the same thing. I'm about to get in the same situation once again and it

always seems to be a pain itself when figuring costs to the doctor or facility. They hire millions just to figure it out.

 

Just wait until the ACA gets all of its share of your insurance money, and it goes through the federal budget process,

like my Railroad Retirement or your Social Security. nothing but more complication then.

[GlockSpock]

When I arrived at work this morning, I checked the insurance packet that we received (the above link is something we received via email before the meeting). This packet we have does list the deductible and annual out-of-pocket maximum as being the same in-network, but it also shows under "office visits" that they are covered 80% no deductible. This should mean that it is 20% coinsurance for an office visit, regardless of how much you have spent that year, right? You deducible and a-o-o-p-m are different when you look at outside network coverage.  Sound right? If this is the case, at least it is worth something. Hopefully the 20% coinsurance payment is also applicable to your maximum out of pocket amount as well.

[Guest sL1k]

My insurance is the same as no insurance . I have to pay 1700 out of pocket before they pay a dime then I have to pay 20 percent up To 3k before they pay 100 percent. I pay $15 a week for that lovely coverage. If I had a family I would have to pay $3500.

Try carrying Cobra to keep a group policy going for about 7 or 8 years and then get individual insurance at the age of 55. Yours would be a very good deal indeed.

I've lived with 5K deductible, 50/50 to $7500 max out of pocket, no copay or coinsurance, for about 8 years now until I recently turned 65. Premium was up to $535 a month when I went on Medicare last month.

They never had to pay a dime, since I never had a serious issue. The only thing paying over $6K a year got me was that I was charged the contracted insurance rate for services, rather than the uninsured rate. As I'm sure yours does too, so it's really not at all "same as no insurance".

Medicare (using freebie Blue Cross Advantage Plan) saves me over $5k a year right off the bat, not to mention free gym membership, which is another $600 just at the YMCA, plus all services are much cheaper than the private insurance rate, $20 doc/$40 specialist, etc.

I'm actually looking into having my elbow fixed, could never afford it before, looks like MRI and surgery will cost me under 500 clams plus another 100 or so for follow up specialist visits.

And I sure appreciate you all chipping in for it!

- OS

Oh I know its better than no insurance or cobra but I rarely ever get sick. So if I do go to the doctor I will always be paying 100 percent which is what I meant by no insurance . If somethin extremely bad were to happen to my body I will be glad to have it. I miss the days of a copay though.

[Glenn]

I believe you must pay the full allowable amount until you meet the deductible, except for the listed exceptions. I would take your plan in a minute. I have a $4800 deductible and another $4800 out of pocket.

[peejman]

I have a slightly different spin on that "high deductible" type plan you have, called an HRA plan.  HRA = Health Reimbursement Account.   Functionally, its the same as the OP's BSBC plan ($2500 family deductible, 80/20 thereafter) with the exception that the company gives you $1000 toward the deductible.  That $1000 is the HRA.  So that account covers the first $1000 of care (which isn't much these days), then I pay the next $1500 to meet the deductible, then we go 80/20 until the out-of-pocket max.  No copays, nothing to pay up front. 

 

The good part is, if you're healthy and don't spend that first $1000, it rolls over to the next year assuming you choose the same plan again.  So if you didn't spend any of it, the 2nd year you'd have $2000 toward your $2500 deductible, and so on.  If the HRA balance exceeds your deductible, its then used to pay for the 80/20 portion if/when that comes up. 

 

The frustrating part is, lots of health providers don't understand how the plan works and I have to explain to (or argue with) them about how it works.  And the provider (UHC) is agonizingly slow to pay the bills, so I regularly get bills from providers for things I don't owe simply because UHC just hasn't paid them yet.  It goes against my nature to not pay a bill when I get it, but if I pay a bill that the insurance should have paid, I won't ever get my money back.  AMHIK. 

Edited August 5, 2013 by peejman

[GlockSpock]

A few emails back and forth between our "insurance guy", and I figured out that office visits are indeed "outside" of the deductible. In my above example, I should have paid $19. Although I don't believe it is any form of HSA, my employer will provide up to $500 to the deductible if you go over $2000, in essence making the employee (but not family) deductible $500 less. I just don't think it rolls over. Overall I guess it is very good insurance, but it is very confusing. Also, quoting our "insurance guy", BCBS has their system setup incorrectly right now that is causing others to experience the same probably that I am seeing. Once it is fixed, an office visit should automatically be 20% of the negotiated amount, without any haggling with receptionists:)

[Glenn]

And if BCBS can't keep it straight, you know the Government is going to get it running smooth.

[Sam1]

I think this needs to be just a bit more complicated