Insurance...Don't Know What the Heck I'm Doing!

Discussion in 'Random Ramblings' started by rodriguezpoultry, Oct 12, 2009.

  1. rodriguezpoultry

    rodriguezpoultry Langshan Lover

    Jan 4, 2009
    Claremore, OK
    So, I felt fairly confident that I knew what to look for in insurance. I am going to get insurance through my job.

    The plans aren't the best, but they're better than what I was looking at.

    Can someone PLEASE explain to me the difference between "out of pocket" and annual deductible? I mean....aren't I paying up to the annual deductible before the plan kicks in? So why is it not included as "out of pocket"???

    Here is the plan I'm "hoping" to get:
    $1250 annual deductible/ $5000 maximum out of pocket/ $250 health credit

    It'll add up to about $36 per paycheck (biweekly).

    Does this sound reasonable?

    I asked about co-pays and such, but the personnel person said that there were no copays in AR. Um...I went to the doctor and there are co-pays...
  2. sfw2

    sfw2 Global Menace

    After you meet the deductible, your insurance pays a percentage of your covered bills. Anything beyond that percentage is your "out of pocket" expense. Once you've met the out of pocket limit, the insurance will pay 100% of your covered expenses.

    Hope that helps!

    ETA: My insurance plan doesn't have a copay - just the deductible and percentage.
    Last edited: Oct 12, 2009
  3. meriruka

    meriruka Songster

    Oct 18, 2007
    I think this is how it works.....

    Annual deductible is the amount you have to pay before the insurance kicks in.

    Out of pocket means that if your policy coves 80% of a procedure the other 20% is your problem.

    So, you go to the doctor all year and you pay everything until you reach your deductible amount. Then say you need surgery, but the insurance only covers 80%. If the surgery is $40000 the insurance will pay 32000 of it leaving a balance of 8000. Since your out of pocket is 5000, you will pay that and insurance will pay the balance and every procedure after that 100% for the rest of the year because you have reached your $5000 out of pocket.

    Is it a good plan? Well if a max per year of $6250 is ok with you, then I guess it is. If not, you could choose one with a lower deductible and less out of pocket, which will make your biweekly premium go up.

    Can't help with the copay thing, sorry.
  4. debilorrah

    debilorrah The Great Guru of Yap

    ROPO!!!! HMO or PPO? that is the first question to be answered. I can help you. I am in charge of new employee insurance here at work.
  5. rodriguezpoultry

    rodriguezpoultry Langshan Lover

    Jan 4, 2009
    Claremore, OK
    Ppo! :d
  6. chickaddict

    chickaddict Songster

    May 4, 2009
    I was a trainer/slave for cigna health for 10 years. Anything with a 5,000 oop is not a great plan. If you opt for this plan make absolutely positively sure that ALL OF YOUR CO-PAYS ARE APPLIED TO YOUR OOP. This often means tracking it yourself. EVERY time you speak to someone at your insurance company TAKE NAMES. The employees that pay claims and the employees that answer phones are usually in 2 different departments. Most customer service reps have NO experience paying claims. They are trained in benefits and phone ettiquette only.

    start a notebook

    Always remember emergency room visits are paid or denied based solely on diagnosis.

    a sprained ankle will get denied as an unneccessary trip to er
    however if you say "I think it is broken" a suspect fracture will always get paid.

    if you go to the er for bronchitis it will be denied, however, if you tell them I am having chest pains(a symptom of bronchitis) it will be paid.

    Feel free to harrass me with any questions, for there is pure enjoyment in helping the underdog actually receive the payments they deserve.

    You wouldn't believe half the crap I've seen them pull on people!!!!

    good luck
  7. BarkerChickens

    BarkerChickens Microbrewing Chickenologist

    Nov 25, 2007
    High Desert, CA
    I have a independent PPO plan that is a $1500 deductible and $3500 out of pocket. That means that all appts, procedures, etc I pay 100% until I reach $1500. Then, after that, my insurance benefits kick in where I pay a copay for appts, etc. Should something happen and I need LOTS of medical care one year, the most I will pay is $3500. That is $1500 plus $2000 in remaining copays that I would be responsible for ($1500 deductible + $2000 copays = $3500 out-of-pocket). Anything over $3500 is covered 100% in for that annual year. Hope that helps! [​IMG]
  8. EweSheep

    EweSheep Flock Mistress

    Jan 12, 2007
    Land of Lincoln
    Quote:LOL I used to be ONE of those type of claims payers and I agree with you that the customer services do not pay claims. All they do is to take your calls, type in the necessary information, and their screeen will give them the claims being paid and how it was processed. Do expect errors from claims payers and we do our darnest to make no mistakes!

    We all rely on DX codes in what we will pay or not pay. Many times we denied, as stated above about pneumonia instead of chest pains. Stupid, yes! And many times when we deny the claims, we would get the same claim with a different DX with the same service in order to pay the claims. Do they get paid with the new revised DX? You bet we did!

    All boils down to the mighty dollar of profits with the company! I was a claims payer for almost ten years until I was terminated unnecessarily but glad to get out. In the future if I had to do it again, yes, I love my job but hated the systems in computers in how we must process. When I left, they downsized ALOT and got a new system set up and everything is automatically in the computer, and the claims payers just pull up a claim and review it and pay it or deny it.

    $5000 is a lot of money to be paid out of pocket and too high of a deductible but like everything else, it goes up.
  9. rodriguezpoultry

    rodriguezpoultry Langshan Lover

    Jan 4, 2009
    Claremore, OK
    It is a high one, but I can't afford paying $75.00 each paycheck. I can hardly afford the one I'll probably be getting.

    Thanks for all the help ya'll!!! [​IMG]
  10. 19Dawn76

    19Dawn76 Songster

    Apr 26, 2009
    Toadsuck, AR
    Is this the insurance that Wal-mart offers?

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