Understanding Insurance lingo

[modhatter]

I was reading through some policies provisions on the exchange last night.
Most all of these policies have deductibles starting a $2,500. Some of the higher priced one's (at least 1/3 higher) have a deductible as low as $750.

My question was this. In looking at some of the plans that have say a $3,000 deductible. Some say this

"Primary Care Visit $35, then 30% after deductible is met"

Others just state a co-pay fee of $35 but say nothing more, and I assumed that started only after the deductible was met.

So what is the first one saying? You can go see your primary doctor for $35, and then after you have reached $3,000, you must pay 30% instead?

That seems odd to me. I did call BCBS and was directed to an agent, but she was unable to answer the question. Anyone have any experience in this?

 

[MichaelB]

You pay the entire cost (insurer negotiated cost) of the service until the deductible has been met. They you pay the co-pay until the entire total out of pocket has been reached, The insurer then pays 100%.

All this is for eligible expenses. Preventive and wellness services (see here) are not subject to any deductible or copay.

 

[Sue J]

Some of the plans I looked at had an Office Visit co-pay only for the first 3 visits. Then it applied to the deductible. Then after you met the deductible it was 30/70 co-insurance.

Got to read the fine print. Then call and ask questions, then read the fine print again.

 

[modhatter]

You pay the entire cost (insurer negotiated cost) of the service until the deductible has been met. They you pay the co-pay until the entire total out of pocket has been reached, The insurer then pays 100%.

All this is for eligible expenses. Preventive and wellness services (see here) are not subject to any deductible or copay.

But it says:
"Primary Care Visit $35, then 30% after deductible is met"

So which is it? You pay $35 to see GP, and after you reach $3,000 than you pay 30%. Seems to imply the $35 co-pay is before deductible is met.
It is worded different from other plans.

Also, I read about the free preventable services. Was wondering if that included your yearly physical. Ours was always pretty skimpy. Listened to your heart, take a deep breath, take your blood pressure, then order a bunch of lab work to see if your insides were working as should be.

I know the lab work isn't included. Someone on another board said his doctor sent him for some blood lab work, and he got a bill for over $600.
I know we don't know what tests he had. Mine were always included in my insurance premium so don't know what they can run.

 

[Sue J]

You can shop around for the allowed amounts for bloodwork. I used to use my Primary Care Physicians in house lab for bloodwork. Very convenient and their retail rate was reasonable. But their negotiated rate was not much smaller than the retail. DH's Dr also did in house bloodwork and his retail rates and negotiated rates were much higher than at my Drs lab.

DH started going to Quest Diagnostic which was nearby. The retail rate is high but the negotiated rate was super low. The first time I saw the bill for what we owed on the negotiated rate I burst out laughing because it was so small compared to what he had been responsible for at his Drs. office lab.

By getting our providers (Drs offices and Quest Lab) Fed tax ID# and the codes for the specific bloodwork I was able to get the negotiated rates from our insurer. We've now both switched to using Quest Diagnostic for our bloodwork.
http://www.questdiagnostics.com/home.html