Need some clarity on how the US health insurance works

Following..

 

Do you have insurance through work or are you buying your own?
I have only had employer-provided insurance, for which I pay a share of the monthly premium.
There are as many insurance plans as there are employers. Each insurance company such as Blue Cross, United Healthcare, Aetna, etc enters into different contracts with employers or individuals, so each person's insurance experience will be different.
I can relate my experience, but it will be different from everyone else's. I usually have a PPO plan, and I picked a physician who has appointments readily available. I do have to wait longer for my ob-gyn appointments, but other specialists have been very easy to see. I do not have children, so no experience with pediatric doctors.
I only go through my insurance for payments. The costs would be staggering otherwise, especially for hospital stays. Even routine blood tests/X-rays/MRI/ultrasounds cost hundreds of dollars without insurance.
For example, a routine visit to my physician incurs a co-pay of $20. She takes $65 per visit without insurance, plus the cost of tests.
I don't understand the part about having higher costs with insurance. You will typically have a co-pay, and the rest of the cost will be covered by the insurance company as per their rules.
It is very important to thoroughly understand the rules your insurer has, and make sure that the providers are in-network in order to get the maximum benefits. There may also be pre-authorizations required for certain tests or procedures. When in doubt, get everything in writing and don't rely on what the reps tell you on the phone.
Also check your bills carefully and do not hesitate to get clarification if something doesn't look right.

 

Basically the insurance wants to pay as much minimum as possible. But without insurance, we would have paid a lotttt more for my delivery. A lot depends on the type of insurance your company offers you. Don't go by your friend. She may or may not have a good coverage. Hospitals may charge more if you have insurance coz it is they who pay for it but the insurance negotiates the fees for you. It is better to be covered in this country or else we will be ripped apart.

 

Hi racr,

How much you pay for a medical check-up or procedure depends a lot on your insurance plan. Some of them have high deductibles, many require authorizations, in-network providers, etc but in general, medical care without insurance is supposed to be way higher. In my case, my employer provides insurance, I pay a small monthly premium and $20 copay for every office visit. Diagnostic tests are fully covered.
Check out what kind of coverage your insurance has. I would advise you not to go by what your friend said. Without insurance even a small surgery would cost you $$$.

 

Sounds to me like your friend is on a bare minimum insurance, the kind that covers hospitalization major operations and emergency room costs but has a high deductible for the routine checkups and preventive care visits. Such insurance usually has a low monthly premium but you pay a lot for doctor visits and pharmacy which go towards the out of pocket or deductible. To get around this high deductible charge, which can be around $2000 per person per year, she is paying cash and not using her insurance card for the regular, non serious kind of doctor visits. So she is trying to save on both ends. Probably she is self -employed or bought her own insurance, not through some employer. If you have employer insurance they are mandated to make sure you have proper coverage, not like this, so you have proper coverage, your employer pays part of your monthly premium also, so pls take advantage of that. You dont need to do all this.
PS: I think there is a very good reason she pays cash and not by CC or check which can be traced. She is scamming the system!

 

We have a high-deductible plan option at work. You have to cover the first $5000 of costs, then the insurance kicks in. In return the premiums are much lower. Single people in excellent health find this to be a good choice for them.

 

Not all employer provided insurance are same either. It all depends on the benefits the employer in question provides. For example, my previous employer was self-insured and had what I thought then to be decent coverage. $20 co pay and $40 specialists. All diagnostic tests were completely covered. When I had my baby, for 3 day hospital stay and everything was very little out of pocket. Don't know the exact amount as my husband took care of all that.

But my current employer, also self insured, is way better. Every year the employer sets a fund - close to $1000- that goes towards copay etc. Only after that fund is exhausted do I have to pay anything out of pocket. Any unused amount can be carried forward. Covers many thing that many other employer sponsored plans do not cover like fertility treatment etc. Both providers were Aetna and both were high deductibles but coverage vastly different.

Your friend is wrong in that doctor's visit wo insurance cannot be cheaper. I could get the doctors I wanted too. Sometimes its harder as a new patient - for example, I wanted a ob/gyn but had hard time getting one that I wanted, but when I called after I was pregnant, suddenly they were easily available.

One last thing, just because one has insurance does not mean a doctor can charge whatever she likes. They have negotiated rates which is the maximum they can charge. And that amount will be way cheaper than what someone with no insurance will pay.

My advice is educate yourself on what your plan covers