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Thu Mar 20, 2014, 04:47 PM

Health insurance fundamentals - deductibles, copays - Help! this makes no sense [View all]

Confusing -- I thought the patient paid EVERYTHING up to the deductible, and the insurance co. paid NOTHING. But John Waski says this:

A Procrastinator’s Guide to Picking an Obamacare Plan, John Waski, FiscalTimes, 3/19/14

{Speaking of Bronze Plans} : For $662 a month, one Blue Cross/Blue Shield plan (in Illinois), offered a preferred provider organization. If providers were in the network — it was more expensive if they weren't — Blue Cross would fully cover all expenses after a yearly family deductible of $12,700 was met. Under that amount, 60 percent of expenses were paid for in this bronze plan. { The last sentence is a big Huh? }

There was a catch, though: After a deductible was met, there would be a 20-percent co-insurance fee for doctor's visits. So let's say that our doctor charged $100 per visit. Before the deductible, the insurer would pay $60 and we'd be on the hook for $40. After the deductible, we'd still have to pay $20 a visit. { The bold sentence is a big HUH? }

All of the policies I surveyed on the bronze level had some sort of "gotcha" that involved additional out-of-pocket costs. Some policies charged 40 percent co-insurance for specialists; others for generic prescription drugs. And the co-payment varied. One higher-premium policy charged a flat $100 for specialists and a 40 percent co-payment for generic drugs.


Here's an example: In a normal year, our family pays about $2,500 in out-of-pocket costs — mostly for doctor's visits and tests. A bronze-level policy would cover $1,500 of that { 1500/2500=60% }, all of which would fall under the $12,700 maximum for most of these policies.

To avoid the potentially costly co-payments on physicians, we'd have to spend $1,000 a month { 12,000 / yr } in premiums in a policy that would suit our present needs — about $300 more a year than we're paying now { $300/month = 3600/yr doesn't add up either, did he mean $400/month = $4800/year? }. But the difference between our present premium ($7,200) and the higher HealthCare.gov policy is $4,800 { 12,000 - 7,2000 = 4,800, at last something checks }, so we wouldn't save any money.

Everything in { braces } is mine.

My understanding of deductibles, coinsurance, and copays is the level of https://www.healthsherpa.com/learn/how-insurance-works
but it is apparently missing an important piece of it like the insurance co paying some costs before the deductible????

In the article above, maybe he used the word "deductible" when he meant "out of pocket maximum", but some of it still doesn't make sense.

I know there are some ACA services that are free, regardless of what ones deductibles and out of pocket maximums and any of that other stuff, like preventive screenings, contraception, and I think one annual wellness visit (or is the last one just Medicare), but in the above I'm talking about the other "non-free" stuff.

Is the author out to sea? Or me? I'm trying to get a policy before the March 31 deadline (yeah, I know I have to pay the first month's premium by then too...) and thought I understood things until reading the above article, and now I'm wondering if I understand a damn thing. Thanks for any comments.

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