General Discussion
Related: Editorials & Other Articles, Issue Forums, Alliance Forums, Region ForumsAm I the only person at DU who knows that "deductible" only applies to hospital stays?
[font size=2 color=blue]On edit: it appears a lot of other people's experiences have been drastically different from mine. According to most DUers, they *do* have to pay the deductible before their insurance kicks in. Still, the following has been my experience under more than one policy using different doctors and medical facilities. So take it for what is worth as one person's anecdote.[/font]
No to mention that in all the ACA discussions, I've never seen mention of the dirty, little secret that once you have insurance, everyone tends to ignore the rules of that insurance.
To your benefit!
When I have had to use car insurance, I had to pay the deductible amount before the insurance would kick in. But not so with medical. Almost everything goes to insurance first.
I have a $400 deductible. But I have never, ever seen it applied. To anything. Not to surgery. Not to doctor visits. Nada.
Disclaimer: I've never had a hospital stay. I think it might apply to that.
I sometimes pay a copay. More often than not, they waive the copay.
Then I get a bill. Since you are new to the insurance game, let me pass along what I long ago learned is rule #1 when receiving the first bill following a medical procedure:
[font size=2]Always Ignore the First Bill [/font]
The medical industry has pre-negotiated rates with insurance companies. Those rates are lower than the rates people without insurance are charged. Your first bill will not reflect that rate. Nor will it reflect the fact that they have already sent the same bill to your insurance company.
I suspect they trick a lot of people into paying a bill this way that patients would not otherwise have to pay.
Next, you will probably receive an itemized statement including the insurance information (I did not last time which caused some confusion). This statement should include:
- initial charge
- insurance agreed rate
- insurance payment
- the portion you are supposed to pay
This will probably come from your insurance company, not from medical. Since you do not make medical payments to your insurance company:
[font size=2]Store and Ignore [/font]
Wait til you get a 2nd bill from medical. Chances are, you won't. I usually don't. They're generally satisfied with what they get from insurance, and don't want to bother with it after that.
You know, they actually offer Associates Degrees in "Medical Billing". That is how totally fucked up it is. But if you follow the above rules, you should be in the clear. And end up paying very little for actual medical care.
Unless they put you on a prescription. Then you're royally fucked. But that is a whole other can o' beans.
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frazzled
(18,402 posts)Many tests and procedures that don't involve a hospital stay are counted into a deductible.
It's why we switched from a PPO, where the annual deductible kept rising (up to $2000 per person) to the HMO version of our insurance (no deductibles at all). One year we had no medical bills until November or so, when my husband's doctor ordered him to have a couple of expensive tests, which he had to fully pay as part of his deductible, and my doctor ordered two foot x-rays, which amounted to $800, paid as part of deductible.
A number of preventive medicine tests (mammograms, colonoscopies) are now covered for free, and don't count to deductible, under the ACA. But if you buy a policy that has a deductible, and you need an X-ray, you'll have to pay for it.
ieoeja
(9,748 posts)They year, I eve had an ultrasound that they paid toward. And I did not satisfy my deductible this year. Yeah, it is really low ($400). But that is the only time I've been to the doctor this year. And I did not rack up $400 in copays, etc in the process.
I've modified the OP to reflect that this is not everybody's experience.
SharonAnn
(13,779 posts)Health Insurance can require a co-pay and deductible amount be met for things other than just hospital stays.
oldhippie
(3,249 posts)I have excellent medical insurance ( the same that Congress currently has) and I have paid many thousands of dollars in deductibles for many outpatient procedures and doctor's in-office procedures Treadmill tests, ultrasound, cataract surgery and many lab tests are just some of the items that require a payment toward the annual deductible.
Blue_In_AK
(46,436 posts)when he did cataract and cornea surgery on me early last year. And then I got bills afterwards, too. I'm still getting them. I'm not sure what's up with that when I was assured before the surgery that the almost $1,000 I paid up front would be all I would be responsible for. The explanation I've gotten makes no sense, but I just keep paying. I've been told this last bill will DEFINITELY be the last, but I'm not holding my breath.
Medicare did pay a lot, though. The problem seems to be with the crazy cost of health care. They charge hundreds of dollars when you're just laying on a table coming out from anesthesia. It's insane.
MadrasT
(7,237 posts)I have a $3000 deductable and I have to pay for everything out of pocket until I reach $3000. Unless it is something covered by a copay, in which case the copay counts toward my $3000.
Also, only the "customary amount" counts toward the deductable. If my doctor charges me $180 and the "customary amount" is $100 according to the insurance company, only $100 of the $180 I actually paid counts toward the $3000.
This is Independence Blue Cross, an employer provided plan, and I am stuck with it.
ieoeja
(9,748 posts)Or do you mean the employer pays in part for the plan (as with me)?
If the latter, then charging you the difference between the cusotmary rate and the doctor's rate should be violating a contract the doctor has with your insurance company. You should notify the insurance company.
It is really weird that I have had so many different doctors, procedures and insurance companies, but I have never, ever run into the problems all the posters responding to this thread have experienced.
Just amazingly lucky, I guess.
Ms. Toad
(34,102 posts)it is just how insurance works.
If you're ignoring bills (as your OP seems to indicate) you will likely receive phone calls from debt collectors in a few years.
Generally you get two bills. One before insurance, and one after. I have had a few instances in which I never received an "after" bill and was hounded by debt collectors for failure to pay the amount left after insurance. They are always delayed by years, so I suspect they just have not caught up with you, and that when you do you will not consider yourself so lucky.
leftstreet
(36,116 posts)
DrDan
(20,411 posts)there may be some procedures and treatments where the deductible does not apply, for example well-woman tests, tests for skin cancer (at least here in Florida) etc. But not all. Depends on your insurance as to where deductibles apply.
A-Long-Little-Doggie
(1,011 posts)because that is not true. There are deductibles for professional (doctor) charges.
ieoeja
(9,748 posts)I have had a dozen different plans over the year. Had three surgeries at two hospitals. Broken bones. Cancer. Numerous tests and procedures. Been xrayed. Had an ultrasound.
And my deductible has never, ever been a factor.
Judging by the fact that everybody else on DU has had just the opposite experience, I must be the luckiest SOB on this site. All those different plans. All those different doctors. And not one of them treated me the way everybody else has been treated.
Weird.
leftstreet
(36,116 posts)Maybe without even realizing it
$400 is very, very low for a deductible
ieoeja
(9,748 posts)And even if I satisfied the deductible, I should have been charged something first to get there. I don't believe I have ever paid $400 on medical care in a single year.
leftstreet
(36,116 posts)ieoeja
(9,748 posts)Losing the first apparently didn't hurt.
Actually, losing the first helped. Because it was an HMO. So when the first doctor told me I had cancer and what needed to be done, he also told me that they would first have to do some useless shit required by the HMO. And I did go through some medical billing hell as they kept trying to collect for nearly a year after I had already paid it.
That is when I learned the "don't pay the first bill" rule. They pretty much told me that is what screwed up their whole system.
leftstreet
(36,116 posts)Regardless of your fortunate insurance circumstances...
Ignoring bills is never good advice
ieoeja
(9,748 posts)They're not going to send you straight to collections. And, as mentioned in the OP, the first bill I have received have always been incorrect. They always send me a bill BEFORE insurance pays.
At that point I have no idea what to pay them. So I really don't have a choice. I have to ignore the bill.
VanillaRhapsody
(21,115 posts)even if the doctor accepts payment from insurance up front or nearly...the doctors office doesn't update your account for weeks possibly months. In the meantime...they will send you bills for the full amount...hoping you will pay it. I got an $8000 bill JUST for anesthesia (after surgery for broken arm done outpatient). I called the insurance company and they showed that bill paid in full. I got the cleared check number and called the doctor...who apologized profusely and said they just hadn't updated my account yet (this was months after surgery) and they were paid within 2 weeks of it.
ileus
(15,396 posts)Every copay out of pocket goes toward our deduct.
My wife had two surgeries and numerous tests this year. When we hit her max she had a 21k surgery. 19k was discounted for being a preferred provider. We ended up owing 2xx after all was said and done.
I also know not paying a clinic/lab/X-ray bill will result in a bill every month. Until its referred to a collection agency. Then the bill every month comes from a different source.
TheKentuckian
(25,029 posts)Certain services may be exempt from the deductible but it does not generally only apply to hospital stays.
NCTraveler
(30,481 posts)ieoeja
(9,748 posts)And I say this because, as I've stated elsewhere, I've haa good bit of work done and have never, ever, not one single time received any care/test/etc that was not partially paid by the medical insurance. My deductible has never been a factor. That has been my experience with different policies from different insurance companies using different doctors in different hospitals.
I'm freaking Midas! All healthcare I touch apparently turns to gold.
okieinpain
(9,397 posts)
NotThisTime
(3,657 posts)You must meet your annual deductible before your insurance will start paying out. I go for medical treatment every 8 weeks, the first treatment of the first year costs me my deductible, then there's my annual out of pocket which I always hit, so by mid year I never pay another dime, but that's because I've paid 3500.00 in medical deductible and co-payments by then....
ieoeja
(9,748 posts)Maybe it's because it doesn't apply to the smaller, routine stuff that I have mostly had over the years. And when I have had a surgery I'm supposed to pay 20% anyway, so that would eat up my deductible immediately.
Except that I've never been billed for that 20%.
leftstreet
(36,116 posts)ieoeja
(9,748 posts)I imagine neighborhood Chicago hospitals are accustomed to people who are unable to pay. I've heard more than one person with the Fire Department say that the city will bill you only once if you use their ambulances. If you pay, great. If not, they just write it off.
It may be that the hospitals are so readily reimbursed by the city that they just don't bother trying to collect.
ChazII
(6,206 posts)have been in the hospital several times these last 3 years. We are both with United Health Care and on the first bill from the hospital in all caps it says DO NOT PAY THIS BILL. He was with our local phone company for 30+ years and I was a teacher for 31 years.
ieoeja
(9,748 posts)
Nye Bevan
(25,406 posts)SOME policies will require you to spend your whole deductible before you start getting coverage for doctor visits. Here is an example:
So for this policy, you will pay the full cost for doctor visits, even in the network, until you have spent $5000. (By "full cost" I mean the negotiated rate between the insurance company and the doctor. Which would probably be something like $80 for a typical visit). Once you have met your $5000 deductible, primary care visits will cost you $15 and specialist visits $25. (Once you have spent a total of $6350, the out-of-pocket maximum, all visits will be free. The $6350 includes the $5000 deductible).
OTHER policies (usually more expensive ones) will waive the deductible for doctor and/or specialist visits. For example:
HERE, you will pay $20 to see a primary care doctor (in network) and $45 to see a specialist (in network) EVEN BEFORE you have used up ANY of your deductible. (That is what "deductible waived" means).
One last thing: preventive care (like annual check-ups) are always free, regardless of the policy deductible and copay. So even under the first policy in this post your annual check-up would be totally free. Also mammograms, colonoscopies and so on.
See: https://www.healthcare.gov/what-are-my-preventive-care-benefits/
Phentex
(16,334 posts)understand that they need to find out what is included in their individual policies. I am not talking ACA necessarily but insurance in general. They do vary greatly, not only from company to company but plan by plan, HMO vs POS vs PPO, etc.
And frankly, it can be hard to understand and know exactly what's covered and what's not until you use it!
Thanks for your post!
DebJ
(7,699 posts)different as to what counts towards the deductible. Another 'fine print' to watch out for as I shop.
Thanks!
frazzled
(18,402 posts)Go figure.
DebJ
(7,699 posts)Since it seems they can be different.....
SheilaT
(23,156 posts)the details. What I do know is that any number of things are covered by the co-pay and never start involving my deductible.
Last year when I had cataract surgery, I paid a fair amount out of pocket because my insurance only covered about a third of it.
crazylikafox
(2,762 posts)I normally don't use a lot of health care. But this past year I had some medical problems, so...
Emergency room: no deductible. (just $200 copay, but everything after that free)
MRI: no deductible (just a % due)
echocardiogram: no deductible
many Dr. & Specialist visits: No deductible, just copay.
other heart tests & lab work: no deductible
Outpatient Cataract surgery: I had to pay my entire $1000 deductible, before the surgery.
So I guess the answer is that policies differ, and we need to read the fine print. Obviously, I must have better insurance than I realized.
Ms. Toad
(34,102 posts)Once you have met your deductible, the coinsurance/copays apply. It isn't a deductible against each separate procedure, but against all (but waived or excluded) costs during the year.
crazylikafox
(2,762 posts)The other medical care & procedures I mentioned were in 2012. The cataract surgery was in early 2013. So yes, the cataract surgery was first THIS year, but the other stuff was in the 4th quarter of 2012. I only paid coinsurance/copays for the 2012 procedures. As I said, it was all Dr. visits, lab work & testing, & emergency room care. No expensive surgery or hospitalization, & no deductible to meet.
Humanist_Activist
(7,670 posts)they pay a damn dime, and even that may not be 100%. This goes for doctor's visits(outside of preventative), diagnostics, x-rays, maybe prescriptions(its unclear on that issue), etc.
uppityperson
(115,681 posts)If what you post is accurate, you had a great policy. The lowest ded I ever had was a thousand, highest was $10 K of which they paid NOTHING until I paid the entire 10 K.
Benefits differ. And co-pays are not typically waived but are what you pay as your part, unless your out of pocket maximum has been met. Ignoring co-pays is cheating and, having been on the receiving end of "I have ins so don't need to pay co-pay", it is very much not appreciated.
eta I do insurance biling so know a bit of what I talk about. Also do not ignore bills, but call the billing place first to make sure they have everything from ins company and to find out what you do owe. It can take months to get the ins settled, so be patient. Once ons has settled, then you talk to biller to see what sort of deal you can cut.
ecstatic
(32,733 posts)and "I feel sick" visits?
In my case, the only times I paid a deductible were for specialist treatment/tests. It applied to an MRI and other non typical outpatient treatment and/or lab tests. I also had to pay a deductible for surgery.
It would be highly unusual for someone to pay the entire deductible for one procedure. There's a maximum out of pocket percentage for each procedure usually 10 to 40%).
Cal Carpenter
(4,959 posts)Many current/new policies require the patient to pay the full amount until the deductible is reached, and in many cases, the patient also pays co-insurance of 30% or 50% beyond that, up to their annual out of pocket max of, say $6,000 or $12,000 (for a family). The out of pocket max is on top of the premiums, btw. Premiums do not count towards the out of pocket max.
Certain basic 'preventative' things are exempt from this - eg an annual check-up / gyno appt, mammograms, obesity testing and a few other diagnostics. But in many policies - including those being found on the exchanges right now - the patient is responsible for every other primary dr visit, specialist visit, etc until the deductible is reached, and then for a portion of the bill (larger than a typical co-pay) until they have reached their annual out of pocket max.
Humanist_Activist
(7,670 posts)I have to pay full price for doctor's visits until the deductible is met if it is not a preventative care visit.
ecstatic
(32,733 posts)I had a PPO INDIVIDUAL plan with BCBS of Georgia and that wasn't true in my case, and again, my insurance was really put to use--surgery, MRI, even a blood transfusion.
I guess we'll know for sure next year, because if what you say is true, people will complain. It could be that the plan descriptions are poorly written. We'll see...
Humanist_Activist
(7,670 posts)Humanist_Activist
(7,670 posts)"You must pay all costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over(usually, but not always January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible."
Even the bolds are in the document as well, no paraphrasing from me above, and I had to type it out, because the plan document I have is from my employer's website, and is a poorly copied PDF file of a printout of the original document.
bhikkhu
(10,724 posts)He had a 5k deductible per person on the policy for his family, and last year wound up with $10k in bills (for several outpatient visits, two people on the policy), which he paid off in installments.
This year he would up in the same situation early, but didn't have the money to pay right away. It was for amounts over what the insurance paid. Fortunately, he took the time to sit down with someone at the hospital finance office who looked over the records. It was just a matter of the hospital billing above the amount the insurance company would pay, and as a matter of course, they wound up adjusting the billing down to what the insurance had already covered. Result: no bill, $7,000 he didn't have to pay that he thought he had to.
I don't know much about health insurance myself (uninsured for 10 years now), but it sounds like "ignoring the first bill" is absolutely the way to go, and that talking to the hospital (or anyone involved) is a good thing to do before getting too distressed.
dionysus
(26,467 posts)($500) with 80% of the cost covered. that's in network.
out of network I have to pay the deductible ($1250) before they cover anything (might be because its a specialist, I don't know), then they cover 60%.
it's a cigna plan.