Understanding Health Insurance Lingo..

[siratfus]

I am a newbie to health insurance would like a little help understanding some things. We are planning to have a baby. I have googled first to understand some basics, but I'm still a bit confused... Here are my questions..

1. Do premiums count towards deductible or out of pocket limit? Must be no, but would like confirmation.
2. Are deductibles included in out of pocket limits?
3. When it says "30% coinsurance after deductible." It means the insurance will pay 70% of the cost only after the patient meets his/her deductible. Meaning on top of the deductible, patients are still responsible for 30% of the services. Is my understanding correct?
4. Does your coinsurance count towards your out of pocket limit? I mean wants you reach your out of pocket limit, you don't have to pay for coinsurance anymore, right?
5. Copays during the year for visits, drugs, etc. These all count towards deductible, right?
6. The hierarchy is this.. Deductible is first, once it's met, if you have coinsurance, then that kicks in. Then at some point the deductibles + the coinsurance should meet the out of pocket limit. Then your home free, everything else is covered after. Is my understanding correct?

Thank you in advance!

 

[Dave020]

I am a newbie to health insurance would like a little help understanding some things. We are planning to have a baby. I have googled first to understand some basics, but I'm still a bit confused... Here are my questions..

1. Do premiums count towards deductible or out of pocket limit? Must be no, but would like confirmation.

No, premiums do not count towards deductibles nor out of pocket maximums.

2. Are deductibles included in out of pocket limits?

Depends on the plan. Sometimes yes, sometimes no.

3. When it says "30% coinsurance after deductible." It means the insurance will pay 70% of the cost only after the patient meets his/her deductible. Meaning on top of the deductible, patients are still responsible for 30% of the services. Is my understanding correct?

Yes, this is the in-network co-insurance portion and it is shared cost. It stops once the out of pocket max is met in-network.

4. Does your coinsurance count towards your out of pocket limit? I mean wants you reach your out of pocket limit, you don't have to pay for coinsurance anymore, right?

Correct, for in-network services.

5. Copays during the year for visits, drugs, etc. These all count towards deductible, right?

Fixed co-pays do not count towards deductible nor out of pocket maximum. On some plans co-pays may cease once OOP is met, on others (like Blue Shield Spectrum) they continue even after OOP is met. Unless HSA, no drugs costs count towards any responsibilities under the medical portion of the plan.

6. The hierarchy is this.. Deductible is first, once it's met, if you have coinsurance, then that kicks in. Then at some point the deductibles + the coinsurance should meet the out of pocket limit. Then your home free, everything else is covered after. Is my understanding correct?

In-network with participating providers, yes. Out of network has a completely different set of benefits levels. You are always responsible for excess charges out of network even if you have hit the out of network out of pocket max. And it is per calendar year and resets every Jan 1st.

 

[siratfus]

Awesome, thank you!

Assuming no complications, just a normal regular birth. What would you say is the best game plan for it? We're only going to get insurance for her. Pay high or low premium plans? Kaiser has the Copayment 25 for $325 a month. No deductibles, no coinsurance, and out of pocket limit is $2500. If a birth is a very large bill, this seems like a good idea. The other one I'm looking at is the Deductible 2700 with HSA, it's $150 a month. But I'm kind of worried of the office visits, "0 after deductible is covered." How much are office visits? Part of the problem in comparing the plans is not knowing what all these medical services cost.

At the end of the day, logic tells me there is no bargain either way. Whether you pick low or high, don't you end up paying almost the same in totality?

How soon can you get pregnant? If our coverage begins on December 15th, 2011?

Lastly, usually what are the benefits of a HSA type plan? Those require us to open a savings account?

I know I should ask Kaiser directly, but I would appreciate some general input, so that I feel more equipped when I get a sales rep on the line. Thanks again!

 

[STIBROKER]

Kaiser has the Copayment 25 for $325 a month. No deductibles, no coinsurance, and out of pocket limit is $2500.

Just one question......with no deductible and no coinsurance....were is the $2500 coming from.........

 

[siratfus]

Just one question......with no deductible and no coinsurance....were is the $2500 coming from.........

I should be asking you. See, these are some of the things I don't understand.

 

[Dave020]

Awesome, thank you!

Assuming no complications, just a normal regular birth. What would you say is the best game plan for it? We're only going to get insurance for her. Pay high or low premium plans? Kaiser has the Copayment 25 for $325 a month. No deductibles, no coinsurance, and out of pocket limit is $2500. If a birth is a very large bill, this seems like a good idea.

This plan is very comprehensive and a good value. Maternity costs can range retail from $10-12k up to $30k or more depending of facility. Many doctors also require you pay a deposit of $1000 - $1500 for the service against your deductible. You won't have to do that with Kaiser.

The other one I'm looking at is the Deductible 2700 with HSA, it's $150 a month. But I'm kind of worried of the office visits, "0 after deductible is covered." How much are office visits? Part of the problem in comparing the plans is not knowing what all these medical services cost.

Likely varies by provider specialty and location.

At the end of the day, logic tells me there is no bargain either way. Whether you pick low or high, don't you end up paying almost the same in totality?

Given you have a known benefit utilization, probably so.

How soon can you get pregnant? If our coverage begins on December 15th, 2011?

I believe the application asks if the applicant is currently pregnant. Basically as long as the birth does not occur (absent extenuating circumstances of course) within 9 months of policy start date, you should be fine.

Lastly, usually what are the benefits of a HSA type plan? Those require us to open a savings account?

Account is optional. Benefits are lower premiums with higher first-dollar responsibility. For many with low or no normal benefit utilization, allows them to keep their money to use later for their medical care or, if not needed, for other types of care.

I know I should ask Kaiser directly, but I would appreciate some general input, so that I feel more equipped when I get a sales rep on the line. Thanks again!

Use an agent, it's free to you.

Use this link for Kaiser: Kaiser IFP Solution - Enter Your Information
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Just one question......with no deductible and no coinsurance....were is the $2500 coming from.........

Inpatient and outpatient co-pays and facility charges.

 

[somarco]

I have a couple of problems with these statements.

We're only going to get insurance for her.

Do I understand you to say, you don't have health insurance now, and, are only considering the purchase now to cover a pregnancy?

I would appreciate some general input, so that I feel more equipped when I get a sales rep on the line

What are you going to do when you have questions after you buy? Deal with KP reps or come back here looking for free advice?

Dave Fluker has been extremely kind to respond to your questions. Why not show some respect and allow him to be your agent?

 

[siratfus]

I have a couple of problems with these statements.



Do I understand you to say, you don't have health insurance now, and, are only considering the purchase now to cover a pregnancy?



What are you going to do when you have questions after you buy? Deal with KP reps or come back here looking for free advice?

Dave Fluker has been extremely kind to respond to your questions. Why not show some respect and allow him to be your agent?

Not pregnant yet.

Shouldn't I talk to KP reps if I buy KP?

I just thought this was a forum to ask questions. Much like any other forum I've gone to for help in technology, home maintenance, etc. I appreciated David's help and he may end up being my agent after all. But right now, I need to gather more info about how this whole system works. And that's why I'm here. To have an agent, see, that's new to me. Now I'm googling.. "Do I need a health insurance agent?" and "What is their job?" I had insurance through my employer for the longest time and was guilty of not even studying it, and barely using it. You just brought up something I never thought about, an agent.

 

[insuremeplz]

I'd compete for your business, but Dave has already beaten me to it. It will cost you nothing extra to go through him as the company pays him a commission to act as your representative. If you have problems or questions once your insurance is in place, it helps to have an agent on your side.

 

[sdmillar]

I'd compete for your business, but Dave has already beaten me to it. It will cost you nothing extra to go through him as the company pays him a commission to act as your representative. If you have problems or questions once your insurance is in place, it helps to have an agent on your side.

Would agree and Dave is a VERY knowledgeable agent to have on your side when and if something come up that you do not understand or want clarification on.... And it does not cost you anymore to have an agent. What a beautiful thing!