Bronze, Silver and Coinsurance/Copay

[audreyh1]

Right now it looks like the Silver plans are the "co-pay" plans with prices set out for Doctor's visits, prescription drugs, various outpatient things, emergency room visits, etc. So when you go for something, it's not a huge amount out of pocket, but you pay higher premiums for that "privilege".

The Bronze plans have no copays, you pay for everything (beyond the basic annual preventative stuff), including prescription drugs, up to the deductible, but you pay lower premiums.

Of course you get the negotiated plan rates in both cases which are the most important thing.

[GLM]

Ok going to ask a basic question this general conversation has me wondering about. When a plan has a co-pay for a doctor visit of say $35, what does that mean? Say I get a bad lung infection and end up seeing my GP. ( I've only done the annual physical thing for ? years - I think I did go for a lower respiratory thing about 18 years ago ) If I have not yet met my deductible do I pay the full negotiated rate or just $35?

I always thought the co-pay only applied after the deductible .

I believe in letting my immune system fighting for me , and it has consistently risen to the task when called upon. Also, I am convinced my regular exercise sort of pasteurizes germs out of my system.

[tinlizzy]

Quote:

Originally Posted by MichaelB Is this it? Federal Rule Allows Higher Out-Of-Pocket Spending For One Year - Kaiser Health News

Yes but it was an article that linked to that. The article was about a couple whose present day insurance plan had no limits on prescription oop and he was dx'ed with cancer and the meds destroyed them financially.

[Texas Proud]

Quote:

Originally Posted by GLM Ok going to ask a basic question this general conversation has me wondering about. When a plan has a co-pay for a doctor visit of say $35, what does that mean? Say I get a bad lung infection and end up seeing my GP. ( I've only done the annual physical thing for ? years - I think I did go for a lower respiratory thing about 18 years ago ) If I have not yet met my deductible do I pay the full negotiated rate or just $35? I always thought the co-pay only applied after the deductible . I believe in letting my immune system fighting for me , and it has consistently risen to the task when called upon. Also, I am convinced my regular exercise sort of pasteurizes germs out of my system.

The copay in my policy (not saying all as I am sure there might be an exception) is how much I pay to see a doctor.... my copay is $50 for GP and $75 for specialist... So, if I go to the doc the first day of the policy year, I pay $50 and insurance pays the rest... this amount does not count toward my deductible...


My DW recently had knee surgery and we had to pay $75 for each physical therapy session.... even after we met the full deductible.... so they keep coming no matter what....

[donheff]

Quote:

Originally Posted by GLM Ok going to ask a basic question this general conversation has me wondering about. When a plan has a co-pay for a doctor visit of say $35, what does that mean? Say I get a bad lung infection and end up seeing my GP. ( I've only done the annual physical thing for ? years - I think I did go for a lower respiratory thing about 18 years ago ) If I have not yet met my deductible do I pay the full negotiated rate or just $35? I always thought the co-pay only applied after the deductible . I believe in letting my immune system fighting for me , and it has consistently risen to the task when called upon. Also, I am convinced my regular exercise sort of pasteurizes germs out of my system.

Quote:

Originally Posted by Texas Proud The copay in my policy (not saying all as I am sure there might be an exception) is how much I pay to see a doctor.... my copay is $50 for GP and $75 for specialist... So, if I go to the doc the first day of the policy year, I pay $50 and insurance pays the rest... this amount does not count toward my deductible... My DW recently had knee surgery and we had to pay $75 for each physical therapy session.... even after we met the full deductible.... so they keep coming no matter what....

I too am a little unclear on this. From the discussion above I got the impression that on some (most?) plans you pay the full amount of the negotiated rate until you reach your deductible and then pay only copays. But it sounds like on others you pay a portion of costs until you have paid out the deductible and then switch over to copays. Is that correct? And how do you all get the plan details? Do you have to go to the insurers site? When I looked at health.gov results I saw only the brief plan summary, no details and no link for details.

[MichaelB]

Every plan has a summary of benefits of coverage. This is where all the information on copays and deductibles, cost sharing and coverage can be found. Here's a plan brochure from BCBS Texas, using a new standardized ACA format http://www.bcbstx.com/pdf/sbc/33602TX0440001a.pdf

For ACA compliant plans, the flat fee co-pay is the only amount one pays for that service, and it is applied to the total OOP. Here's a helpful PDF by BCBS on how cost sharing works https://consumerdirect.bcbsfl.com/si...0813_Final.pdf

[jflynn4]

Quote:

Originally Posted by GLM Ok going to ask a basic question this general conversation has me wondering about. When a plan has a co-pay for a doctor visit of say $35, what does that mean? Say I get a bad lung infection and end up seeing my GP. ( I've only done the annual physical thing for ? years - I think I did go for a lower respiratory thing about 18 years ago ) If I have not yet met my deductible do I pay the full negotiated rate or just $35? I always thought the co-pay only applied after the deductible . I believe in letting my immune system fighting for me , and it has consistently risen to the task when called upon. Also, I am convinced my regular exercise sort of pasteurizes germs out of my system.

Every plan is different ... You need to read the details involved with the specific plans you're considering. Some do require you pay "all" up to the deductible, some you pay a flat fee, and others you pay to the max out of pocket.

[audreyh1]

Quote:

Originally Posted by MichaelB Every plan has a summary of benefits of coverage. This is where all the information on copays and deductibles, cost sharing and coverage can be found. Here's a plan brochure from BCBS Texas, using a new standardized ACA format http://www.bcbstx.com/pdf/sbc/33602TX0440001a.pdf For ACA compliant plans, the flat fee co-pay is the only amount one pays for that service, and it is applied to the total OOP. Here's a helpful PDF by BCBS on how cost sharing works https://consumerdirect.bcbsfl.com/si...0813_Final.pdf

Interesting. It looks like you have to go to a Gold plan to have coverage for out-of-network providers.

[audreyh1]

I stand corrected. The Bronze plans do address out-of-network providers. The shorter summaries I found only mentioned you may be responsible for the balanced-bill charges after what BCBSTX pays which sounded like it was open-ended to me.

One of the Bronze plans - http://www.bcbstx.com/pdf/sbc/33602TX0420005a.pdf

Well, actually, they all (including Gold) say "balance-billed charges" do not count toward the out-of-pocket limit. Hmmm - I suspect that is no different than what I have today. It is indeed open ended.

Thanks so much MichaelB for directing more towards these more comprehensive docs. Oh boy - more research!

[MichaelB]

Quote:

Originally Posted by audreyh1 Interesting. It looks like you have to go to a Gold plan to have coverage for out-of-network providers.

I just pulled a random plan out. Still, from your and other's comments, it appears that BCBS Florida has much greater variety of offerings than BCBS Texas, and also much more pricing disparity. That favors the knowledgeable choice - if such a thing can exist in healthcare insurance. If there were any doubt, it also shows that insurers find competitiveness in complexity. The comparisons are now becoming easier, but they are still a long way from easy, and estimating a realistic total cost is still quite challenging.

The plan I linked is a multi-state plan. They are being offered as part of the ACA rollout, but so far I have seen no mention of them at any BCBS website and can only find info when I google the plan name. Plan names can be found on this web page http://www.opm.gov/healthcare-insura...-plan-program/

[donheff]

Quote:

Originally Posted by MichaelB I just pulled a random plan out. Still, from your and other's comments, it appears that BCBS Florida has much greater variety of offerings than BCBS Texas, and also much more pricing disparity. That favors the knowledgeable choice - if such a thing can exist in healthcare insurance. If there were any doubt, it also shows that insurers find competitiveness in complexity. The comparisons are now becoming easier, but they are still along way from easy, and estimating a realistic total cost is still quite challenging. The plan I linked is a multi-state plan. They are being offered as part of the ACA rollout, but so far I have seen no mention of them at any BCBS website and can only find info when I google the plan name. Plan names can be found on this web page Multi-State Plan Program and the Health Insurance Marketplace

Assuming the ACA moves forward, I expect that, as early as next year, multiple sources will start publishing comparison services coinciding with each open season. Some free and others (more comprehensive I would hope) for a fee. These sorts of guides have been available for the Federal Health Benefits Program (which is similar to an ACA exchange) for years.

[tinlizzy]

Quote:

Originally Posted by audreyh1 Interesting. It looks like you have to go to a Gold plan to have coverage for out-of-network providers.

Insurance plans sometimes have exceptions to this rule that allow coverage. Based on my experience I think this is common.

My current insurance (medical and dental) allows in-network coverage for out-of-network providers if there are no in-network providers within 25 miles.

Aetna Dental - they had no oral surgeons in-network when my son had his wisdom teeth pulled.

BCBS of IL - they had no general surgeons in-network when I had my gall bladder out.

[GLM]

Quote:

Originally Posted by GLM Ok going to ask a basic question this general conversation has me wondering about. When a plan has a co-pay for a doctor visit of say $35, what does that mean? Say I get a bad lung infection and end up seeing my GP. ( I've only done the annual physical thing for ? years - I think I did go for a lower respiratory thing about 18 years ago ) If I have not yet met my deductible do I pay the full negotiated rate or just $35? I always thought the co-pay only applied after the deductible .

Thanks all ! Michael B the link was useful .I now think I clearly get that copay and coinsurance are different things that may or may not overlap. I have not had a copay in years - from before preventative care was covered. Coinsurance for me is so far away - above our 11K deductible it has sort of been off my radar. Now I feel more up to speed for when (if ? ) I do finally get my idenity verified and I can see my healthcare.gov options

[Texas Proud]

Quote:

Originally Posted by donheff I too am a little unclear on this. From the discussion above I got the impression that on some (most?) plans you pay the full amount of the negotiated rate until you reach your deductible and then pay only copays. But it sounds like on others you pay a portion of costs until you have paid out the deductible and then switch over to copays. Is that correct? And how do you all get the plan details? Do you have to go to the insurers site? When I looked at health.gov results I saw only the brief plan summary, no details and no link for details.

The simple answer is that it can be both....

My current plan has copays from the very first dollar spent.... I can go as many times as I need....

Reading some plans that are private, some have NO copay until you max out on the deductible.... IOW, if your deductible is $5K, you have to spend $5K before you start to have a reduced cost for copay services... as in a Dr. visit.... so, under this plan you pay your $5K, then the next time you go to the doc you pay your copay amount... this means you have no sharing of costs prior to you maxing your deductible....

As I mentioned, my current plan is sharing costs on my first Dr. visit... I have a flat rate for that visit no matter what the doc does (well, not really as I have had sometime had to pay for a procedure now and again)....

The is another option that I have seen on the exchange.... it will say you get 3 or 6 visits at a certain copay amount.... if you go more than that you pay 100% of the cost until you max your deductible... you then go back to the copay amount...

[47]

Quote:

Originally Posted by audreyh1 Great, Thanks - and to Ziggy too. I never quite got that. Yeah - I guess that is meaningless to me as a consumer. I just think in terms of X amount per year for doctors visits, copays, etc. that are not covered - I either pay the insurance company, or I pay the clinic/doctor directly. So $100 a month goes to one or the other. $1200 would cover a lot of doctor's visits (basic screening is already included in the policy, so mammogram, physical, basic blood work, etc. is already paid for by the policy). So in general, that $1200 would be for "extra" stuff, and still applies towards the deductible. The max-out-of-pocket per year is the main issue for us. No cost-sharing or subsidies for us. I hope that makes signing up easier.

Even if there is a slight chance that you may fall in to the subsidy range (a lay-off, unplanned ER(!) or some such) you may be better off signing up inside the exchange so that you don't close off the option of getting subsidies for the months prior to the event. If your income is investment heavy an unexpected/unplanned capital loss toward the end of the year can do it.

[Texas Proud]

Quote:

Originally Posted by 47Percent Even if there is a slight chance that you may fall in to the subsidy range (a lay-off, unplanned ER(!) or some such) you may be better off signing up inside the exchange so that you don't close off the option of getting subsidies for the months prior to the event. If your income is investment heavy an unexpected/unplanned capital loss toward the end of the year can do it.

I just have a question on this....

Do you HAVE to sign up in the exchange to get a subsidy Or do you just need to do it to get a current subsidy? IOW, if you do not get a subsidy now, and you should have received one..... don't you get it back on your tax return

[audreyh1]

Quote:

Originally Posted by tinlizzy Insurance plans sometimes have exceptions to this rule that allow coverage. Based on my experience I think this is common. My current insurance (medical and dental) allows in-network coverage for out-of-network providers if there are no in-network providers within 25 miles. Aetna Dental - they had no oral surgeons in-network when my son had his wisdom teeth pulled. BCBS of IL - they had no general surgeons in-network when I had my gall bladder out.

Sorry - I corrected this in the next post. All the plans have the same out-of-network coverage and stipulations. Just different deductibles, copays, max OOP, etc.

So you are vulnerable to balance billing with an out of network provider in all cases. BTW Medicare does not allow this - for a patient to be sent a bill above what Medicare pays.

As for exceptions - yes, out of network is covered under certain situations, but not the most common case which is a hospital or a doctor/surgeon is on the plan, but some of their providers, such as an anesthesiologist, are not.

[audreyh1]

Quote:

Originally Posted by MichaelB I just pulled a random plan out. Still, from your and other's comments, it appears that BCBS Florida has much greater variety of offerings than BCBS Texas, and also much more pricing disparity. That favors the knowledgeable choice - if such a thing can exist in healthcare insurance. If there were any doubt, it also shows that insurers find competitiveness in complexity. The comparisons are now becoming easier, but they are still a long way from easy, and estimating a realistic total cost is still quite challenging. The plan I linked is a multi-state plan. They are being offered as part of the ACA rollout, but so far I have seen no mention of them at any BCBS website and can only find info when I google the plan name. Plan names can be found on this web page Multi-State Plan Program and the Health Insurance Marketplace

I was wrong about the out of network thing - it's identical in all TX plans.

In terms of total realistic costs - there are some potentially open ended costs, but if it is no worse than what I have now, I'm OK with that at the moment.

I found the multiple state plans on the BCBSTX website - same doc as yours. They are listed prominently under the individual plan choices - HMO, PPO, or Multi-State PPO.

[47]

Quote:

Originally Posted by Texas Proud I just have a question on this.... Do you HAVE to sign up in the exchange to get a subsidy Or do you just need to do it to get a current subsidy? IOW, if you do not get a subsidy now, and you should have received one..... don't you get it back on your tax return

My understanding is that the only way you are even in the subsidy system is if you go through the exchange.

The complex back-end government systems that deal with of IRS/ MAGI/identity/SSN/dependents/household size etc are all plugged into and interface only through the exchange. Of course they also have to deal with the complexities of the insurance companies and the myriad of plans on top of that. That's the primary reason the exchange sites are having a difficult time getting off the ground.

So even at the tax return time, they will only know the details of your interaction with the exchange. Anything you do outside of the exchange is dealt with at arms length just for verifying that you had qualified insurance during that period.

[REWahoo]

Quote:

Originally Posted by 47Percent My understanding is that the only way you are even in the subsidy system is if you go through the exchange.

That's my understanding as well.

I saw this article earlier today saying those who have their current individual policy canceled and elect to take their insurer's offer to switch to a new ACA policy won't get a subsidy even if they qualify because they bypassed the exchange.