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?

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.

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.

No worries at all, and just to clarify, those concepts are pretty universal to all health insurance plans in the US.

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.

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

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

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