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A little confused

Started by williamspace, January 09, 2017, 04:02:51 PM

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williamspace

So I just got off the phone with a less than helpful insurance representative. I'm still a little confused.

My insurance is BCBS Anthem.

Basically the most useful info he gave me is I pay everything until my deductible, then it's paid 80-20. Which is only slightly helpful because I have no idea what being paid 80-20 means. Basically, what I'm looking for is help? Has anyone else had this insurance?


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AlyssaJ

So you have a deductible of say $4500 (or whatever yours is for your coverage).  That means you pay for 100% of your medical expenses up to that amount.  Once that amount is reached, Anthem will pay 80% of the costs and you still need to pay the other 20%.  That continues until you reach your out of pocket maximum (varies by coverage, might be like $10,000) where then Anthem pays 100%.

The amount you've paid toward your deductible and out of pocket maximum gets reset to 0 each year and the whole thing starts again.
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williamspace

Quote from: lisawb on January 09, 2017, 04:10:39 PM
So you have a deductible of say $4500 (or whatever yours is for your coverage).  That means you pay for 100% of your medical expenses up to that amount.  Once that amount is reached, Anthem will pay 80% of the costs and you still need to pay the other 20%.  That continues until you reach your out of pocket maximum (varies by coverage, might be like $10,000) where then Anthem pays 100%.

The amount you've paid toward your deductible and out of pocket maximum gets reset to 0 each year and the whole thing starts again.

You are more helpful than the insurance rep I talked to, thank you.


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AlyssaJ

No worries at all, and just to clarify, those concepts are pretty universal to all health insurance plans in the US.
"I want to put myself out there, I want to make connections, I want to learn and if someone can get something out of my experience, I'm OK with that, too." - Laura Jane Grace

What's it like to transition at mid-life?  http://transitionat40.com/



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FTMax

Hi, yes. The only figure they've left out is your out of pocket maximum. Then you'll know exactly what you'd pay. So basically:

Your deductible is the minimum amount you are expected to pay toward your healthcare costs during a premium period. For example, mine is $3,000. I am expected to pay $3,000 toward my healthcare expenses from July 1 2016 - June 30 2017. And this includes everything - doctor visits, prescriptions, lab work, etc. After I've paid $3,000, my insurance pays 80% of the remaining bills. I would be expected to pay the remaining 20% balance of the bill up to the value of my annual out of pocket maximum.

Example:

I have surgery. It costs $20,000.
I pay my deductible of $3,000. The balance due falls to $17,000.
Insurance pays out 80% of the $17,000 bill, or $13,600.
I owe another $3,400 UNLESS the amount I have paid thus far this year exceeds the value of my out of pocket maximum.

My annual out of pocket maximum is $10,000. Adding together my $3,000 deductible plus this 20% balance owed gets us to $6,400. Under my plan, I would be expected to pay all of that. If I continued to have further medical bills throughout the year, I could be asked to contribute another $3,600 towards those expenses. Usually it doesn't come to that if you're going to all in network providers.

Now, let's say my out of pocket maximum was only $5,000. I'd be expected to pay my $3,000 deductible. But when we get to the balance owed, as long as the provider is in network with my insurance, I would only be expected to pay another $2,000. Insurance would pick up the remainder or it would be written off per the provider's agreement with insurance. I don't think you can be balance billed once a provider has agreed to accepting an insurance payment, though you'd want to check with your provider about their practices. I know all 3 bottom surgeons I consulted with said they would not balance bill me.

Hope this helps! If you have specific #s you're looking at with your plan, I'm happy to help further.
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JoanneB

As others pointed out, 80/20 is "Insurance Speak" for "We pay 80%, you pay 20%" after the deductible comes totally out of YOUR pocket.

The details of why is how insurance actuarials make their money
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Denise

Oh but wait... There is in-network and out-of-network doctors.  Everything mentioned above is the same but for out of network the numbers are not in your favor.

deductable
   In: 1500
   Out: 3600
Pays:
    In: 80/20
    Out: 60/40
Max
    In: 12000
    Out: 25000

Keep records.

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Denise

Anything you pay to in-network doctors deductable is applied to out-network.

Sent from my LG-H820 using Tapatalk

1st Person out: 16-Oct-2015
Restarted Spironolactone 26-Aug-2016
Restarted Estradiol Valerate: 02-Nov-2016
Full time: 02-Mar-2017
Breast Augmentation (Schechter): 31-Oct-2017
FFS (Walton in Chicago): 25-Sep-2018
Vaginoplasty (Schechter): 13-Dec-2018









A haiku in honor of my grandmother who loved them.
The Voices are Gone
Living Life to the Fullest
I am just Denise
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