Hellobee Boards

@snowjewelz: yup, that's how ours works.

The problem is it was explained to me (last year) the way you were told your plan works. It wasn't true. We got burned.

@Torchwood: The thing with going to an out of network (OON) provider is that they're not contracted with the insurance company. So they can charge whatever they want to, and the insurance company will pay what they think is "reasonable and customary" for your area.

For example, when you go to an in-network (INN) provider for a doctor visit, they charge the insurance company $100. Because they have a contract with your insurance company, and the insurance says they'll only pay the doctor $80 for that service, the doctor accepts that amount and agrees not to bill you for the balance.

When you go to an OON provider, there is no contract that the provider has with the insurance company that says they won't bill you for the remaining amount of their charge. For something like L&D, that can get extremely expensive. So if the doctor charges $20,000 for the L&D and the insurance company thinks a delivery in your area should only cost $5,000, you'll owe your OON deductible, then 20% of the $5,000...PLUS, the OON provider can bill you for the remaining $15,000 because they don't have a contract with the insurance company that says they won't bill you for the rest. It's called balance billing. That's what ends up burning people on the OON side of things.

@Mrs. Jump Rope: Very good point. It does sound like @snowjewelz: has a plan where there's an individual deductible and a family deductible. So it should stop when she's hit her own individual, and her newborn will have it's own deductible and OOP Max.

@2PeasinaPod: So even though they specifically say they pay 60% of out of network costs for L&D (and 100% for routine preventative care), they might turn around and basically not do that? What's the point of having deductibles and out of pocket maxes for out of network, if they're not going to pay what they say they will? DH is calling at some point today about all this anyway, both the insurance company and his company. I'm just trying to figure out what to expect and what he should ask.

@2PeasinaPod: We have no one in at least a 100 mile radius. That's the farthest out I can even check. I checked for Memphis (200 miles away), and nothing there either. So hopefully it'll be fine and they'll make an exception? It's so frustrating! Thanks for your help!

@snowjewelz: Thanks. It's especially frustrating because the company chose to move us to TN, and if we were still in CO it wouldn't be an issue!

@2PeasinaPod: I also still don't get why they even have a max out of pocket if it essentially has no bearing on what we'll be billed. None of this makes any sense!

@Torchwood: Right...that's the part that annoys me too. They present it as if all you'll have to pay is 40% when they know darn well that the provider can charge pretty much whatever they want to...and that should be disclosed. It infuriates me that it's not.

@2PeasinaPod: My insurance is horrible and we are battling them right now and no one can give us a straight answer for our costs, but they are quick to send us big bills for regular stuff. So the ultrasound at your first appointment, and another at a following appointment because of the lack of the ability to find a heartbeat, should those be coded as "diagnostic ultrasounds?" If not, what should they be?

@snowjewelz: hmm, I always thought the deductible was part of the coinsurance. Maybe that's limited to our company and not standard practice?

But I'm glad you got clarification!

@snowjewelz: Per ACA, your deductible does have to count towards your OOP max...so whatever they set your OOP Max at, the deductible will count towards that. It's just a matter of determining what the OOP Max is!

@Boogs: An Ultrasound, labwork and tests of those nature are all considered diagnostic. It depends on if they're being billed as part of the "normal" course of action when it comes to maternity or outside of that. Usually, your first U/S at 12 weeks and one additional U/S after that is covered as part of a "normal, healthy" pregnancy. Anything outside of that is usually outside of what they consider "Normal and healthy".

So you're likely going to be billed for those ultrasounds if you haven't met your deductible yet. If you want, I can take a look at your explanation of benefits (EOB) if you want to PM me!

@snowjewelz: Since you said your fact sheet is a few years old, it's likely $4,700. The new law just went into effect 1/1/2014, so they probably updated the OOP Max to $4,700 to make your plan consistent with what it was last year rather than make it richer this year.

Hah...I've been in this field for the last 11 years. As things change and new laws come out, we all learn together! Health Care is an ever changing area for sure...

@snowjewelz: the way it works is that you would pay the first $700 of your non-routine medical expenses out of pocket (though you may receive discounts since your insurance may have negotiated rates with your provider on certain things), then after you pay that $700 deductible, you would get the 80/20 until you hit your out of pocket maximum. After you hit the out of pocket maximum, 100% will be covered.

Hope this helps! Disclosure: I work for a major insurance company but the information above is my personal opinion and not the opinion of my employer (Sorry, we have a social media policy where I have to add that for anything insurance related. )