Question regarding insurance in US

Question

I was an international student and my insurance was covered by my university. I only need to pay the copay to see a doctor and everything will be covered.

I am now working. My company is a big company and I join the blue cross plan. Every other week, I need to pay around a hundred dollars.

Recently, I visited a doctor. I had a simple test on site. I paid $100 for copay and then I received a $200 bill after my insurance covered $800. In order words, the doctor charged $1100 and I need to pay $300 out of my pocket. The $100 copay was already too much for me. I did not know that I need to pay another $200.

Because it was so expensive, I did not find a solution of my health problem. I would want to know whether any insurance that I can buy to cover the blue cross does not cover?

Thanks

Answer 1

Generally, when you decide about which health insurance option to choose from, you should be presented with a list of options, their costs, and what and how they cover.

That includes the premium per paycheck that you pay, the copay you need to pay on every visit or with every prescription, the deductibles, the out of pocket minimums/maximums, etc. You then compare and decide which one to take.

It is very uncommon for large employers to only have one option, usually there are 2-3 different options (PPO, HMO, High Deductible, etc). During the next enrollment period check, compare, and choose the one that fits your needs best.

In the mean time contact your current insurer and get all these details, and try to understand how this whole thing works. If you're going to a non-emergency pre-scheduled doctor visit without at least having a general idea how much it is going to cost you - you're doing something wrong.

Call your insurer, check what and how they cover, who's in their network, how the reimbursement process work, and understand that you're not a college kid any more and you're in the world of grown ups. Noone will teach you these things, you'll have to learn yourself.

Answer 2

From what I can tell, you have a very typical plan for the US.

• You have a co-pay. This will always come out of your pocket each time you have a medical event.

• You have a deductible. Generally this is the amount you must pay out of your pocket before the insurance will pay any portion of your charges.

• You have a co-insurance. After your deductible is met, the insurance company will pay a (usually) majority percent of all qualified medical expenses. This could be 80%, for example.

• You have an out-of-pocket maximum. As it suggests, this is the maximum you will ever be required to pay out-of-pocket for medical expenses in the year while insured under the plan. Usually this is very high.

All of this is complicated by certain rules, some of which may be unique to the plan. For example: Copays do not count towards your deductible. There is different coverage depending on if the doctor/clinic is in-network or out-of-network for your plan.

In your case, you probably have not met your deductible, so the $200 will count towards that. It is likely that the insurance did not 'pay' $800, but since the doctor was in-network, the doctor accepts the contractually agreed lower amount dictated by the insurance agreement.

If you are confused by now, don't panic. Welcome to the US medical insurance system. It will take time and patience to learn how the system works. I would suggest talking to HR at your company and asking for help understanding your current plan. Find out what your financial liability is under the plan so you can predict your medical expenses!

Some other suggestions:

• Save up an Emergency Fund. You need this to cover your deductibles and co-pays. You should have one with enough cash to cover you for at least 3 months of expenses.

• You can look into medical gap insurance. I would recommend a strong emergency fund over this option. Medical gap insurance essentially helps cover medical expenses that fall outside of your current plan.