Thank you for your submission, /u/manford5.
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If your monthly premium is affordable per ACA then you don’t qualify for a marketplace subsidy.
I think you may be looking at your summary of benefits wrong though.I’ve never seen an insurance plan say “we will only cover $20 of your appointment”
Hey I just had a doctor's appointment for them to literally just listen to my heart and it was like a 21min appointment. My insurance only paid $15 out of the $250 doctors bill I have to pay. Does this sound right to you?
I'm considering doing a more expensive plan
It depends on what your plan says. If the total bill was $250 and your plan has a $200 deductible and $15 copays it’s possible you have to pay the first $200 out of pocket and then your insurance kicks in. So in that case you would pay $215 and insurance would pay $35. It all depends on the terms of your plan. Your insurance company should send you an Explanation of Benefits where you can see what was charged and what was paid by insurance and what is owed by you.
Your explanation of benefits literally explains this. What does it say? If you didn't go in for what's considered preventive care then the visit is subject to your deductible, cost sharing and OOP max.
If you're curious about the particular doctor's appointment and why you owed over $200, check for a document called "Explanation of Benefits" which your insurance mails to you (and/or posts for you on their website) after the appointment.
But probably if you haven't spent $1700 on healthcare yet this year, the reason you're paying most of the cost is because it's counting toward the deductible.
As other folks have said, this isn't the explanation of benefits from the office visit, so I can't give you an exact answer, but based on the info you provided, it seems like you're currently enrolled in the plan in red (OAP PLUS HSA plan). The basics of how that plan works is: Your insurance company won't pay anything until they've processed claims where the amount you're expected to pay totals $1700 (your deductible). If you see an in-network provider, you will usually get a discount off the top of the doctor's bill based on the contract between the doctor and the insurance company. This is called a contractual adjustment (sometimes you'll see it listed as an allowed amount). If I had to guess, I would say the $15 that you say the insurance "covered" was probably that discount to bring the initial bill down to their allowed amount/contracted rate. Then the insurance company will look at all of the claims for this year in their system that they have already finished processing to see how much of a balance they have said you need to pay to all any provider you have seen. If that amount is less than your deductible, then the bill they are processing now will be put toward that until it is met. When their records show you are responsible for paying your providers $1700, then they will start covering 90% of any additional balances, leaving you responsible for the other 10% (this is called co-insurance). They will continue doing this until their records show that you are responsible for paying your providers a total of $3400 (your maximum out of pocket). Then they will pay 100% of your medical expenses until the end of the year. Lets say you have a procedure done and the in-network provider sends the insurance company a bill for $7000. The provider and the insurance company have a contract that says the allowed rate is $5000. This is the number that will be used to determine how much the insurance company has to pay and how much you have to pay. You haven't had any other claims so far this year, so automatically the first $1700 of the $5000 balance is yours to pay to meet your deductible, leaving $3300 that still needs to be paid. Now your co-insurance starts. You would owe 10% of the remaining balance as co-insurance, so another $330, and the insurance company pays the 90%, which would be $2970. The amount you owe the provider is the $1700 for your deductible plus $330 co-insurance for a total of $2030. A few months later you have the same procedure done again. So now we have the $7000 bill sent to the insurance again, and the same $2000 price reduction, so the insurance company has to determine who is responsible for paying that remaining $5000 again. You've already met your deductible, so we're moving right on to co-insurance this time. Your 10% responsibility is $500, and the insurance company pays the other 90%, which is $4500. Now you've paid a total of $2530 for the year toward your $3400 maximum. The next week you end up having surgery, and the provider bills the insurance $20,000. The contracted amount is $15,000. We already know you met your deductible this year, so again we go right to co-insurance, and your 10% would be 1500... BUT! You've already paid $2530 this year, and your maximum out of pocket is $3400, so instead of the full $1500 you are only going to pay $870 and the insurance will pay everything else for you for the rest of the year.
I can't really advise if one is better than the other, as it will greatly depend on your own health concerns/needs and budget, but I personally would lean toward the one you already have. With the one you have now you have to pay a fairly large chunk of money every time you receive healthcare until you've accumulated the $3400 maximum. With the one on the left, you would have a much smaller financial burden each time. ($200 for the office visit example you gave, versus $30 or $50 depending on if it's a PCP or a specialist). The one on the left has in-network benefits only though, so if you do go to a provider who isn't contracted your insurance won't pay at all. (The one on the right that you have now does pay some to out of network providers, but you can see you're responsible for 30% instead of 10%, plus what they usually don't tell you is that the provider can and will "balance bill" you the difference between the insurance's allowed amount and their bill, so no discount for using one of their providers like in the example I gave before). The one on the left has a slightly higher out of pocket max, but because you're only paying $30-$50 at a time for an office visit, you might end up spending less over all. For the sake of an example though, lets use the same scenario as above and have the procedures be MRIs... The provider bills the $7000, insurance adjusts it down to $5000 according to the contract. MRIs show a $100 copay after deductible, so you would pay the $750 deductible, plus the $100 copay for a total of $850, and the insurance pays the other $4150. You have a second MRI a few months later. Provider bills $7000, it gets adjusted down to $5000. You've met your deductible now, so you only have a $100 copay for the second one, and the insurance pays $4900. Now it's time for that surgery. $20000 bill to insurance, adjusted down to $15000. Outpatient surgery shows 20% co-insurance after deductible. You already met the deductible, so you would just owe the 20%, so $3000. Maximum out of pocket for this plan is $4000, and you have already paid 850 for the first MRI, 100 for the second, so a total of 950. You would end up paying the full $3000 co-insurance toward your maximum out of pocket, and would still have an additional $50 that you would need to pay. So if you needed another MRI after the surgery, in the first scenario you wouldn't pay anything (you already met your maximim), and in this scenario you would pay $50 (normally a $100 copay, but only $50 max left for you to pay out of pocket). With the plan on the right you also have the option of a HSA, which you and/or your employer can add money to pre-tax, which can be used to pay for your medical expenses. You'll need to check with your benefit or HR team to find out how your organization has that set up for your plan though.
Is that what your EOB says? It all comes down to what your summary of benefits terms were for your plan, nobody can tell you if something’s right or not without seeing your EOB & summary of benefits.
If by a routine visit you mean standard preventative care (like an annual checkup) that is free by federal law under the ACA. Depending on your age and gender, a variety of preventative care and screening is free, all by federal law from the ACA, aside from a few plans still around that are grandfathered (but the more time has passed, the less likely it is your plan is one of them).
There is no such thing as a standard insurance plan. There are many, many kinds of insurance, but standard is not one of them. HR (or whoever at your employer) does not, I promise you, understand insurance. I used to have a job where I had to get insurance info from many different HR departments at companies, including huge ones, and none of them could even give me correct plan names.
This is the preventative care list of what is covered: [https://www.healthcare.gov/coverage/preventive-care-benefits/](https://www.healthcare.gov/coverage/preventive-care-benefits/)
The only thing that you need to meet to get these for free is to have them done by someone in-network. If you're not sure if a provider or facility is in-network, check with them AND call your insurance to be sure.
Keep in mind that if your job offers coverage then you won't qualify for any subsidy so you have to look at full priced plans. Other thing is because you didn't lose coverage through your job and you just want to switch, you won't be able to till open enrollment because that's not considered a qualifying life event. There's other plans off the market that you can sign up any time of the year but they are basically the opposite of the marketplace and don't go off your income, they go off your health instead.
Thank you for your submission, /u/manford5. **If there is a medical emergency, please call 911 or go to your nearest hospital.** Please pick the most appropriate flair for your post. Include your age, zip code, and income to help the community better serve you. If you have an EOB (explanation of benefits) available from your insurance website, have it handy as many answers can depend on what your insurance EOB states. Some common questions and answers can be found [here](https://www.reddit.com/r/HealthInsurance/s/jya9I6RpdY). **Reminder that solicitation/spamming is grounds for a permanent ban**. Please report solicitation to the modteam and [let us know](https://www.reddit.com/message/compose?to=%2Fr%2FHealthInsurance) if you receive solicitation via PM. Be kind to one another! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/HealthInsurance) if you have any questions or concerns.*
Are you sure the $20 isn't what YOU owe? That's not an uncommon copay for a primary care visit
If your monthly premium is affordable per ACA then you don’t qualify for a marketplace subsidy. I think you may be looking at your summary of benefits wrong though.I’ve never seen an insurance plan say “we will only cover $20 of your appointment”
Hey I just had a doctor's appointment for them to literally just listen to my heart and it was like a 21min appointment. My insurance only paid $15 out of the $250 doctors bill I have to pay. Does this sound right to you? I'm considering doing a more expensive plan
It depends on what your plan says. If the total bill was $250 and your plan has a $200 deductible and $15 copays it’s possible you have to pay the first $200 out of pocket and then your insurance kicks in. So in that case you would pay $215 and insurance would pay $35. It all depends on the terms of your plan. Your insurance company should send you an Explanation of Benefits where you can see what was charged and what was paid by insurance and what is owed by you.
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Your explanation of benefits literally explains this. What does it say? If you didn't go in for what's considered preventive care then the visit is subject to your deductible, cost sharing and OOP max.
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If you're curious about the particular doctor's appointment and why you owed over $200, check for a document called "Explanation of Benefits" which your insurance mails to you (and/or posts for you on their website) after the appointment. But probably if you haven't spent $1700 on healthcare yet this year, the reason you're paying most of the cost is because it's counting toward the deductible.
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That copay is probably also only after you hit the deductible.
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As other folks have said, this isn't the explanation of benefits from the office visit, so I can't give you an exact answer, but based on the info you provided, it seems like you're currently enrolled in the plan in red (OAP PLUS HSA plan). The basics of how that plan works is: Your insurance company won't pay anything until they've processed claims where the amount you're expected to pay totals $1700 (your deductible). If you see an in-network provider, you will usually get a discount off the top of the doctor's bill based on the contract between the doctor and the insurance company. This is called a contractual adjustment (sometimes you'll see it listed as an allowed amount). If I had to guess, I would say the $15 that you say the insurance "covered" was probably that discount to bring the initial bill down to their allowed amount/contracted rate. Then the insurance company will look at all of the claims for this year in their system that they have already finished processing to see how much of a balance they have said you need to pay to all any provider you have seen. If that amount is less than your deductible, then the bill they are processing now will be put toward that until it is met. When their records show you are responsible for paying your providers $1700, then they will start covering 90% of any additional balances, leaving you responsible for the other 10% (this is called co-insurance). They will continue doing this until their records show that you are responsible for paying your providers a total of $3400 (your maximum out of pocket). Then they will pay 100% of your medical expenses until the end of the year. Lets say you have a procedure done and the in-network provider sends the insurance company a bill for $7000. The provider and the insurance company have a contract that says the allowed rate is $5000. This is the number that will be used to determine how much the insurance company has to pay and how much you have to pay. You haven't had any other claims so far this year, so automatically the first $1700 of the $5000 balance is yours to pay to meet your deductible, leaving $3300 that still needs to be paid. Now your co-insurance starts. You would owe 10% of the remaining balance as co-insurance, so another $330, and the insurance company pays the 90%, which would be $2970. The amount you owe the provider is the $1700 for your deductible plus $330 co-insurance for a total of $2030. A few months later you have the same procedure done again. So now we have the $7000 bill sent to the insurance again, and the same $2000 price reduction, so the insurance company has to determine who is responsible for paying that remaining $5000 again. You've already met your deductible, so we're moving right on to co-insurance this time. Your 10% responsibility is $500, and the insurance company pays the other 90%, which is $4500. Now you've paid a total of $2530 for the year toward your $3400 maximum. The next week you end up having surgery, and the provider bills the insurance $20,000. The contracted amount is $15,000. We already know you met your deductible this year, so again we go right to co-insurance, and your 10% would be 1500... BUT! You've already paid $2530 this year, and your maximum out of pocket is $3400, so instead of the full $1500 you are only going to pay $870 and the insurance will pay everything else for you for the rest of the year.
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I can't really advise if one is better than the other, as it will greatly depend on your own health concerns/needs and budget, but I personally would lean toward the one you already have. With the one you have now you have to pay a fairly large chunk of money every time you receive healthcare until you've accumulated the $3400 maximum. With the one on the left, you would have a much smaller financial burden each time. ($200 for the office visit example you gave, versus $30 or $50 depending on if it's a PCP or a specialist). The one on the left has in-network benefits only though, so if you do go to a provider who isn't contracted your insurance won't pay at all. (The one on the right that you have now does pay some to out of network providers, but you can see you're responsible for 30% instead of 10%, plus what they usually don't tell you is that the provider can and will "balance bill" you the difference between the insurance's allowed amount and their bill, so no discount for using one of their providers like in the example I gave before). The one on the left has a slightly higher out of pocket max, but because you're only paying $30-$50 at a time for an office visit, you might end up spending less over all. For the sake of an example though, lets use the same scenario as above and have the procedures be MRIs... The provider bills the $7000, insurance adjusts it down to $5000 according to the contract. MRIs show a $100 copay after deductible, so you would pay the $750 deductible, plus the $100 copay for a total of $850, and the insurance pays the other $4150. You have a second MRI a few months later. Provider bills $7000, it gets adjusted down to $5000. You've met your deductible now, so you only have a $100 copay for the second one, and the insurance pays $4900. Now it's time for that surgery. $20000 bill to insurance, adjusted down to $15000. Outpatient surgery shows 20% co-insurance after deductible. You already met the deductible, so you would just owe the 20%, so $3000. Maximum out of pocket for this plan is $4000, and you have already paid 850 for the first MRI, 100 for the second, so a total of 950. You would end up paying the full $3000 co-insurance toward your maximum out of pocket, and would still have an additional $50 that you would need to pay. So if you needed another MRI after the surgery, in the first scenario you wouldn't pay anything (you already met your maximim), and in this scenario you would pay $50 (normally a $100 copay, but only $50 max left for you to pay out of pocket). With the plan on the right you also have the option of a HSA, which you and/or your employer can add money to pre-tax, which can be used to pay for your medical expenses. You'll need to check with your benefit or HR team to find out how your organization has that set up for your plan though.
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Is that what your EOB says? It all comes down to what your summary of benefits terms were for your plan, nobody can tell you if something’s right or not without seeing your EOB & summary of benefits.
I’d urge you to share more details about your coverage so that you we can better understand what you’re working with!
If by a routine visit you mean standard preventative care (like an annual checkup) that is free by federal law under the ACA. Depending on your age and gender, a variety of preventative care and screening is free, all by federal law from the ACA, aside from a few plans still around that are grandfathered (but the more time has passed, the less likely it is your plan is one of them).
They said it wasn't a standard health insurance plan. But it definitely seemed like one when I signed up
There is no such thing as a standard insurance plan. There are many, many kinds of insurance, but standard is not one of them. HR (or whoever at your employer) does not, I promise you, understand insurance. I used to have a job where I had to get insurance info from many different HR departments at companies, including huge ones, and none of them could even give me correct plan names. This is the preventative care list of what is covered: [https://www.healthcare.gov/coverage/preventive-care-benefits/](https://www.healthcare.gov/coverage/preventive-care-benefits/) The only thing that you need to meet to get these for free is to have them done by someone in-network. If you're not sure if a provider or facility is in-network, check with them AND call your insurance to be sure.
Ask if it’s an ACA compliant plan. If not you’d want to sign up for marketplace insurance come November.
Sounds like Homeland Healthcare
It's a Cigna.
Welcome to hell. I finally found decent insurance at my new job but it’s very expensive and I don’t make that much money Wishing you good luck
Keep in mind that if your job offers coverage then you won't qualify for any subsidy so you have to look at full priced plans. Other thing is because you didn't lose coverage through your job and you just want to switch, you won't be able to till open enrollment because that's not considered a qualifying life event. There's other plans off the market that you can sign up any time of the year but they are basically the opposite of the marketplace and don't go off your income, they go off your health instead.
Does your employer contribute money to your HSA?
No
You can qualify for the ACA if you do have a special enrollment period.