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  #1  
August 17th, 2007, 10:54 AM
CameraLinds's Avatar Zane & Jude's mama
Join Date: Mar 2007
Location: UK
Posts: 23,138
ok this is gonna probably be a stupid question......but i hope and pray someone can help me out....

i never understood how insurance worked cause my family got it because of my dad's job (federal/gov't job) and now that i'm married i'm not on theirs obviously. and since we're TTC obviously we should/need to break done and get insurance....

oh and insurance/benefits aren't offered at hubby's job...he's freelance so we're on our own...hence why i need help because we don't understand it.

ok i have another question...and i hope you can possibly answer it for me. here is were i'm just sooo confused with health insurance...

i found a plan that has a zero deductible, a co-insurance of 30% and a co-pay for $30.....does this mean for each dr visit we just pay $30? or do we pay the whole bill then get reimbused 30%?

or what about a plan with a 2900 deductible, coinsurance of 40% and a co-pay of 40, does this mean you have to pay all of each dr bills till you reach your deductible and then there after you pay 40 for each visit? but on the same site i found another plan that the deductible was 2000, coinsurance 30% and for co pay it said $35 after deucitble. the plan i mentioned aboved didn't say that.

see this is why i'm so confused. i think i'm reading into everything too much and just confusing myself more. i've read the "howthingsworks.com" article on insurance and stuff adn i still don't get it!!

and what does this mean? "Negotiated fee until Out of Pocket Maximum is met, then covered in full" this is what one plan said under the co-pay.

if you could help great!! if not that's fine. maybe someone else can!?

thanks!!! and sorry for my blondeness
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  #2  
August 17th, 2007, 11:17 AM
paganempath
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You've come kinda to the right place since there are a few ladies from the Financial Board that are regulars here as well. I am not one of them. I'll let them answer your questions for you because I don't want to give you inaccurate info or confuse you further with any explanation that I would attempt.
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  #3  
August 17th, 2007, 11:24 AM
dzine21's Avatar Platinum Supermommy
Join Date: Feb 2006
Location: Mid USA/Corn fields
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Co-pays are what you pay each visit to the doctor. Mine is $25-every visit-until pregnancy. If you are looking into insurance for pregnancy/TTC- check our the prenatal part of the plan if there is one. Then you most likely will pay a larger sum in payments to cover the entire thing. Then again, some insurances may be different. I'm guessing you should ask the ladies on the budget board. They're really good at this stuff. I'm not.
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  #4  
August 17th, 2007, 11:24 AM
soninole's Avatar Platinum Supermommy
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Location: Florida
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Quote:
i found a plan that has a zero deductible, a co-insurance of 30% and a co-pay for $30.....does this mean for each dr visit we just pay $30? or do we pay the whole bill then get reimbused 30%?[/b]
This one sounds like you would have a $30 copay for a doctor's visit. Now that may just be a primary doc like a internal med o family doctor. the 30% may apply to specialists, testing, labs, surgery.....etc

Quote:
or what about a plan with a 2900 deductible, coinsurance of 40% and a co-pay of 40, does this mean you have to pay all of each dr bills till you reach your deductible and then there after you pay 40 for each visit?[/b]
this one I would interprete as a $40 copay for doctor's visit with no ded. Then the $2900 ded would apply to eveything else

Quote:
deductible was 2000, coinsurance 30% and for co pay it said $35 after deucitble. the plan i mentioned aboved didn't say that.[/b]
and this one, you would pay out of pocket until you reached $2000 then a $30 copay would apply to the doctor's visits



Quote:
and what does this mean? "Negotiated fee until Out of Pocket Maximum is met, then covered in full" this is what one plan said under the co-pay.[/b]
this means that you have a maxium amouth that you would have to pay each year, say that figure is $5000. That would mean that once you paid a total of $5000 with your deductible and copays(if they are included in your out of pocket) then the insurance company would pay 100% of all covered expenses for the rest of the policy year.

and the negotiate fee is say your doctor bills $100 for a visit. Well he has a contract with certain insurance companies to accept less from them for that same visit. Say the negotiated fee is $60 for that same visit. That would be the amount that you would pay. The other $40 is written off. And only the $60 would go towards your deductible.


I hope that what I said is clear. And I am going from what I read in your post. You would want to verify this with whatever agent you buy your insurance through. Insurance is very confusing. And I know in Florida it is very expensive to have a private insurance policy with a maternity rider. I was cheaper to pay for all maternity expenses out of pocket. Cause the maternity policy was an extra $180 a month and there was an 18month waiting period. So verify that the policy would cover maternity without an additional rider. HTH`

Edited to add----that the coinsurance would apply after the deductible has been met.
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  #5  
August 17th, 2007, 11:43 AM
CameraLinds's Avatar Zane & Jude's mama
Join Date: Mar 2007
Location: UK
Posts: 23,138
Quote:
Quote:
i found a plan that has a zero deductible, a co-insurance of 30% and a co-pay for $30.....does this mean for each dr visit we just pay $30? or do we pay the whole bill then get reimbused 30%?[/b]
This one sounds like you would have a $30 copay for a doctor's visit. Now that may just be a primary doc like a internal med o family doctor. the 30% may apply to specialists, testing, labs, surgery.....etc

Quote:
or what about a plan with a 2900 deductible, coinsurance of 40% and a co-pay of 40, does this mean you have to pay all of each dr bills till you reach your deductible and then there after you pay 40 for each visit?[/b]
this one I would interprete as a $40 copay for doctor's visit with no ded. Then the $2900 ded would apply to eveything else

Quote:
deductible was 2000, coinsurance 30% and for co pay it said $35 after deucitble. the plan i mentioned aboved didn't say that.[/b]
and this one, you would pay out of pocket until you reached $2000 then a $30 copay would apply to the doctor's visits



Quote:
and what does this mean? "Negotiated fee until Out of Pocket Maximum is met, then covered in full" this is what one plan said under the co-pay.[/b]
this means that you have a maxium amouth that you would have to pay each year, say that figure is $5000. That would mean that once you paid a total of $5000 with your deductible and copays(if they are included in your out of pocket) then the insurance company would pay 100% of all covered expenses for the rest of the policy year.

and the negotiate fee is say your doctor bills $100 for a visit. Well he has a contract with certain insurance companies to accept less from them for that same visit. Say the negotiated fee is $60 for that same visit. That would be the amount that you would pay. The other $40 is written off. And only the $60 would go towards your deductible.


I hope that what I said is clear. And I am going from what I read in your post. You would want to verify this with whatever agent you buy your insurance through. Insurance is very confusing. And I know in Florida it is very expensive to have a private insurance policy with a maternity rider. I was cheaper to pay for all maternity expenses out of pocket. Cause the maternity policy was an extra $180 a month and there was an 18month waiting period. So verify that the policy would cover maternity without an additional rider. HTH`

Edited to add----that the coinsurance would apply after the deductible has been met.
[/b]
thanks soo much.
so if there's not deductible you just pay the co-pay for each drs. visit correct?? and of course the monthly premium.
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  #6  
August 17th, 2007, 11:47 AM
soninole's Avatar Platinum Supermommy
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Location: Florida
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Quote:
thanks soo much.
so if there's not deductible you just pay the co-pay for each drs. visit correct?? and of course the monthly premium.[/b]

correct! That is the type of insurance policy I prefer but they are usually more expensive premium wise. I hope that you find a policy that works great for you. I used to do medical billing so I can answer many of your questions, but every policy is different.
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  #7  
August 17th, 2007, 11:51 AM
donomama
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Sonja pretty much covered it all. Just make sure to read the fine print. Insurance plans often have a waiting period before you get pregnant, and won't cover you if you get pregnant in that window, even if you have coverage. I see that you're already TTC, so you may want to get one that doesn't have a waiting period, although I have never heard of any insurance covering a pregnancy if you buy the policy after you are already pregnant, since it is then considered to be a pre-existing condition, so be careful!
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  #8  
August 17th, 2007, 11:53 AM
soninole's Avatar Platinum Supermommy
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Location: Florida
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Wanted to clarify, that you would have your Doc visit copays and then xrays, testing, etc would be at a percentage or a copay for those.


And I wanted to add, that if you decide on a policy without a maternity rider make sure that they would cover complications during a delivery. For example a c-section. In that case, the insurance would cover the c-section and followup like any other surgical procedure.
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  #9  
August 17th, 2007, 12:00 PM
CameraLinds's Avatar Zane & Jude's mama
Join Date: Mar 2007
Location: UK
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thanks so much!! thanks for the advice and tips. i think i am finally understanding it!
Yep ttc...but we're planing on using a midwife and doing homebirth...we just figured how much for it we would have to pay since they are usually like a bundled cost for prenatal, delivery, etc...from what i found. i know some accept insurance but not sure how/if they would accept the one without deductible or what not. any ideas?

ps- we haven't contacted the midwife that we're thinking of using, because we're not expecting yet. but once we get there we will be calling her

thanks again!
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  #10  
August 17th, 2007, 09:00 PM
MandiK's Avatar Platinum Supermommy
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The previous posters pretty much covered it. Do you have a midwife in mind already? If so, you should check the insurance program you're looking into for their list of approved providers. The coverage amount that the insurance company offers will only applied to 'approved providers' from their list. You'll have to pay full price for any (and every) one else. So, you'll want to see if the midwife is one of those listed. Even with a home birth, you'll need a maternity rider for office visits, labs, prenatal testing, and the possibility of complications.

Feel free to ask away. There are a number of with either medical or insurance backgrounds.
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  #11  
August 21st, 2007, 12:30 PM
CameraLinds's Avatar Zane & Jude's mama
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ok here i am again...thanks so much ladies for your help....
i just want to be 100% clear that i am understanding...

i was just researching plans again...and for i.e. i found one that was 1000 ded., 30% co-insurance and a $35 co-pay....

we have a midwife in mind...what if the plan doesn't have maternity coverage, how/would that work witht he midwife? do you mean i'd need/should have maternity coverage? or would i be able to use the co-insurance and stuff for lab work and stuff if and when i get pg? i need to see if the midwife is on the list.

this is how/what i understand from your help...we pay the monthly premium, that's a given, and at dr's appts we pay the $35 co-pay, but for anything else like surgeries, hospitalization, er visits, tests, lap work etc we pay the 30% and that goes towards the ded. once the ded. is met then we don't pay anything? is this correct? i am just confused with the ded., co-insurance and co-pays all in one plan together.

and for a plan that has a 0 deductible we would pay the monthly charge and then the co-pay for doctors but yet again the other stuff would be the 30% co-insurance? correct?

thanks so much. i jsut want to fully understand it and get the best plan for us.

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  #12  
August 21st, 2007, 01:32 PM
MandiK's Avatar Platinum Supermommy
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As far as premiums, co-pays, and deductibles are concerned you've got it.

As far as maternity coverage ... now, I've never needed it, but I *can* tell you that most insurance policies will cover NONE of your maternity care if you don't have maternity coverage specified in your package. So, any doctor's visit, lab work, ultrasound, delivery, etc would not be covered unless you have it provided for in your rider (insurance policy). In fact, a lot of companies will have nothing to do with any of it. Maternity care is expensive! Count up the number of anticipated doctor's visits, add five more that you didn't think of, then add up all the lab test costs (which would be straight out of pocket, not the insurance's discounted rate), add to that the cost of two or so ultrasounds, tech fees, radiography, plus whatever a night or two in the hospital costs these days for TWO (yes, baby gets billed too), and you've got what it will cost you to have a complication free vaginal delivery. If you have a C-section, need a NICU, etc it will be HUGELY more than whatever you estimate.

I'd get the maternity rider.
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  #13  
August 21st, 2007, 01:33 PM
soninole's Avatar Platinum Supermommy
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Location: Florida
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Quote:
ok here i am again...thanks so much ladies for your help....
i just want to be 100% clear that i am understanding...

i was just researching plans again...and for i.e. i found one that was 1000 ded., 30% co-insurance and a $35 co-pay....

we have a midwife in mind...what if the plan doesn't have maternity coverage, how/would that work witht he midwife? do you mean i'd need/should have maternity coverage? or would i be able to use the co-insurance and stuff for lab work and stuff if and when i get pg? i need to see if the midwife is on the list.[/b]
If you do not have a maternity coverage/rider insurance will not cover anything that is pregnancy related, not labwork midwife, nothing

Quote:
this is how/what i understand from your help...we pay the monthly premium, that's a given, and at dr's appts we pay the $35 co-pay, but for anything else like surgeries, hospitalization, er visits, tests, lap work etc we pay the 30% and that goes towards the ded. once the ded. is met then we don't pay anything? is this correct? i am just confused with the ded., co-insurance and co-pays all in one plan together.[/b]
no, this means that you will pay $35 copay for dr visits-that is correct
but for eveything else it will work like this.....
you will pay all expenses until the $1000 deductible is met then you will pay 30% coinsurance, the insurance company will not pay anything until you reach that deductible.
the only time that you will not pay anything is if you meet your maxium out of pocket for the year. (if your policy has that) I think that you are confusing deductible and maxium out of pocket.

Quote:
and for a plan that has a 0 deductible we would pay the monthly charge and then the co-pay for doctors but yet again the other stuff would be the 30% co-insurance? correct?[/b]
correct

I know that all of this is confusing. Insurance companies are famous for confusing members. Good luck in your insurance hunt. Just remember to ask about maternity coverage, get specific details about it. I have had insurance agents not explain it clearly to me.


ETA: Mandi is absolutely correct about c-section being expense. My hospital bill for an uncomplicated c-section was over $14,000. That did not include the doc, anesthiologist, or Pediatrician
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  #14  
August 21st, 2007, 01:37 PM
MandiK's Avatar Platinum Supermommy
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Look at us posting at the same time ... lol.
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Definition (Webster's 2006) of "MandiK":
A 20something, graduate student, college prof, tree hugging, time managing, coupon addicted, cosmetic selling, dirt worshipping, girl who is in love with Ben and welcomed Sofie Grace on 1/31/11.
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  #15  
August 21st, 2007, 01:39 PM
soninole's Avatar Platinum Supermommy
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Quote:
Look at us posting at the same time ... lol.[/b]

I saw that. Now she is going to be oveloaded with info. LOL
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