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Old 02-18-2010, 12:53 PM   #1
ASIAN JUL
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Help me understand health insurance?

So, can anyone school a n00b on health insurance? I've been looking into personal health insurance since my work doesn't cover it. I found this plan, it was called the Keystone HMO $20 CoPay plan and I found it on ehealthinsurance.com

It almost sounds too good to be true with no annual deductible and only $20 co-pays for a primary physician. The plan got a 4.5 out of 5 rating, though.

Quote:

Plan Type

HMO

Office Visit for Primary Doctor
$20 Copay

Office Visit for Specialist
$30 Copay

Coinsurance
None

Annual Deductible
None

Separate Prescription Drugs Deductible
$250 Individual
$750 Family

Prescription Drugs
Generic: $15 Copay after prescription deductible
Brand: $25 Copay after prescription deductible
Non-Formulary: $35 Copay after prescription deductible

Annual Out-of-Pocket Limit
None

Lifetime Maximum
Unlimited

Health Savings Account (HSA) Eligible
No

Out-of-Network Coverage
No

Out of Country Coverage
Yes. Emergency and Urgent Care Only through BlueCard Worldwide
No idea if I'll be approved for it, but before I jump the gun I was wondering if anyone could explain how this works in simple terms?

Thanks
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Old 02-18-2010, 01:07 PM   #2
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can you get a PPO plan?

you should make sure your primary physician is in the network- sounds like if it's not in the network you're SOL.
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Old 02-18-2010, 01:20 PM   #3
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That plan is probably fairly expensive. PPO will be even more so. If you're not perfectly healthy expect to pay extra and not have those pre-existing conditions covered. Prescription plan isn't too hot either that's a good sized deductible if you ever need expensive pills.

Keystone isn't too bad though I hear. Whatever you do don't lie about past medical history, if you ever have a serious bill even completely unrelated to it they will screw you guaranteed.

Read the fine print when you get the policy, if you miss something they will not.
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Old 02-18-2010, 01:42 PM   #4
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Quote:
Originally Posted by igo4bmx View Post
can you get a PPO plan?

you should make sure your primary physician is in the network- sounds like if it's not in the network you're SOL.
I don't even know what HMO or PPO stands for, I should probably look that up. I honestly don't even have a primary physician, I haven't even found a 'regular' doctor because I have yet to change from my pediatrician.

Quote:
Originally Posted by mann View Post
That plan is probably fairly expensive. PPO will be even more so. If you're not perfectly healthy expect to pay extra and not have those pre-existing conditions covered. Prescription plan isn't too hot either that's a good sized deductible if you ever need expensive pills.

Keystone isn't too bad though I hear. Whatever you do don't lie about past medical history, if you ever have a serious bill even completely unrelated to it they will screw you guaranteed.

Read the fine print when you get the policy, if you miss something they will not.
As of right now, I have no diagnosed pre-existing conditions. I don't take any prescriptions as of now either, so. I don't know. What is smarter? To get a low monthly fee, high deductible plan?
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Old 02-18-2010, 02:17 PM   #5
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Both plans have dr's that are called a "network". All you have to do is make sure that you have doctors that you like in your area.

HMO=you pick a primary care dr, then when you need to see a specialist you need to get a referal from the primary care dr's office. then it is sent electronically to the specialist office.

PPO=same as HMO except you dont need to get referals. generally more expensive.

You will have to to do the math to figure out if its cheaper for you in the long run. If you are sickly then you want low deductible. If you plan on seeing the dr only in extreme cases, then you can want to keep your monthly costs low and decductible high. figure out what works better for you.

I am not sure but i think that medical expenes are tax decductible.

Last edited by angdefeo; 02-18-2010 at 02:20 PM.
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Old 02-18-2010, 02:17 PM   #6
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With an HMO, you would need to select a Primary Care Physician (PCP) who is responsible for all your medical care. As a woman, you should see if this includes a gynecologist or if you can find a "full service" PCP that provides female care, before you enroll. Also with an HMO, you would need a referral from your PCP for any services they do not provide (labs, xrays, specialists) The copay/coinsurance/annual out of pocket limit: You will pay $20 for each visit to your PCP, this is your copay. Coinsurance: your insurance plan pays for a percentage of your eligible medical expenses and you’re responsible for the remaining balance (IE: you pay 20% they pay 80%). You don't have to worry about that with this plan. There is no limit on your annual out of pocket expense. Some insurance plans cap the amount per individual and family, once you have met this limit, the plan covers 100% of the eligible expenses. It also doesn't cover anything out of network, so any cost incurred from visiting a non-participating provider will be 100% your responsibility.

All in all, it doesn't seem like a bad plan, and at least it's insurance. I deal with employee benefits at my job, so if you have any questions, just let me know; I'll be happy to look into something for you.
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Old 02-19-2010, 02:35 AM   #7
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I am pretty dumb on this subject as well. The plan she posted seems pretty legit, but can someone run how a deductible works again in lay-mans terms. I always get psyched out when I see "$250 deductible" or some high dollar thing like that because I feel like I have to pay that up front? I take generic drugs 9 times out or 10.
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Old 02-19-2010, 09:19 AM   #8
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Quote:
Originally Posted by DPancoast View Post
I am pretty dumb on this subject as well. The plan she posted seems pretty legit, but can someone run how a deductible works again in lay-mans terms. I always get psyched out when I see "$250 deductible" or some high dollar thing like that because I feel like I have to pay that up front? I take generic drugs 9 times out or 10.
Deductable is the same as on your auto insurance--you pay the first xxx amount, with the x being your deductable, they cover after that, but usually at a percentage these days. If you hate doctors and are healthy, high deductable is good. If you have diabetes or asthma or any other condition where you see the doc more than once a year on a regular basis, low deductable is good. Kind of like if you're living in Princeton, or Camden. If you live in camden you don't want a 2,000 deductable on your auto theft policy

But the parts by SiR about caps are not quite right...caps are usually referred to as the most the INSURANCE will pay.
Quote:
Some insurance plans cap the amount per individual and family, once you have met this limit, the plan covers 100% of the eligible expenses. It also doesn't cover anything out of network, so any cost incurred from visiting a non-participating provider will be 100% your responsibility.
caps are a BAD thing because if you are in a wreck, then rehab, when you reach your 1 million or whatever cap, they STOP paying altogether. So if you get cancer or some other life altering condition you want NO caps. (which usually makes an expensive plan). As for HMO vs PPO this is made into a bigger issue than needs be, most PCPs will hand out referalls to specialists like its nothing, and on top of that most lay people don't know when they should see a specialist vs PCP. I am a big proponent of PCPs because they tend to see the big picture and not just the 'parts' they are looking at.

In vs out of network, this depends on the carrier. Keystone is a big plan and they have a big network from what I hear. The important thing is that the ER and emergencies are 100% covered out of network. So if you are traveling to california and get hit by a truck or come down with the swine flu you are not getting 20% of the $150,000 bill.

If you go the HMO route don't worry about getting a PCP that does OB as well, you should only need one referral to an OB and from then on you can just see them as you like.

I'm interested to hear what its going to end up costing you though, it was 400 to COBRA mine almost 10 years ago now, and that's at like half of what it actually cost...
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Old 02-19-2010, 09:23 AM   #9
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Quote:
Originally Posted by DPancoast View Post
I am pretty dumb on this subject as well. The plan she posted seems pretty legit, but can someone run how a deductible works again in lay-mans terms. I always get psyched out when I see "$250 deductible" or some high dollar thing like that because I feel like I have to pay that up front? I take generic drugs 9 times out or 10.
They really try to make it as complicated as they can. I think this is so you get so confused that you don't know how fight your bills.

There are comprehensive and non-comprehensive deductibles. The deductible is the amount you are responsible for before your insurance pays. (Think car insurance.) Say your annual deductible is $250, you pay the first $250 of medical bills then your insurance company will pay the remainder of your health care costs based on your policy terms. A non-comprehensive deductible doesn't include services, usually such doctor's visits or prescriptions, in the annual amount, while a comprehensive deductible includes all services. However, prescriptions sometimes have a separate deductible.

This often works in conjunction with your coinsurance. With a $250 deductible and 82/20 coinsurance, if you had a $1000 medical bill, you would pay the $250 deductible, then 20% of the remaining $750 (or covered services) so your minimum out of pocket cost is $400 ($250-$150.)

EDIT: mann, you are correct, but there is nothing about such a limit in the original post. If you read it again, I was referring to the annual out of pocket expense, which has no cap set in this particular plan, not the insurance max-out.

Last edited by Yes SiR; 02-19-2010 at 09:29 AM.
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Old 02-19-2010, 09:51 AM   #10
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So what does this mean?

Annual Out-of-Pocket Limit

None

Lifetime Maximum
Unlimited

Does that mean there is no limit to how much I pay out of pocket?
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Old 02-19-2010, 10:25 AM   #11
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Quote:
Originally Posted by ASIAN JUL View Post
So what does this mean?

Annual Out-of-Pocket Limit

None

Lifetime Maximum
Unlimited

Does that mean there is no limit to how much I pay out of pocket?
i'm not sure but you should see what they do for non- routine visits.

for example with my benefits the company pays 90% of a medical bill (non routine i.e. emergency room visit)
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Old 02-19-2010, 10:54 AM   #12
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Quote:
Originally Posted by ASIAN JUL View Post
So what does this mean?

Annual Out-of-Pocket Limit

None

Lifetime Maximum
Unlimited

Does that mean there is no limit to how much I pay out of pocket?
Yes. But it isn't necessarily as bad as it sounds; most people don't reach their annual limits anyway. It doesn't mean it is automatically a bad plan. If you're worried about it, see what other available plans have a limit. But don't let that number fool you, either. You'll almost always end up paying more than it appears on paper, no matter how great your insurance is.

I know you had some health concerns, which I assume is why you are looking into this. I don't know if you currently have insurance, but in NY, any pre-existing conditions must be covered if you have been uninsured for a period of 11 months or longer. I would look into any plan's policy on pre-existing conditions, regardless of your current insurance status. Insurance companies are doing anything they can to disqualify people from being covered.
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Old 02-19-2010, 07:05 PM   #13
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Move to Canada, become citizen, problem solved

What is the monthly or weekly fee?
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Old 02-19-2010, 07:12 PM   #14
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ah, thanks for the info guys. It just didn't make sense when I first read it because I cant see ever needing $250 in prescriptions haha
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Old 02-19-2010, 07:18 PM   #15
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ah, thanks for the info guys. It just didn't make sense when I first read it because I cant see ever needing $250 in prescriptions haha
That's the point of insurance. Get diagnosed with cancer w/o insurance... (or any major disease/illness), good luck.
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Old 02-19-2010, 07:21 PM   #16
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yeah I understand.. just never saw it like that I guess
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Old 02-19-2010, 08:14 PM   #17
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Move to Canada, become citizen, problem solved

What is the monthly or weekly fee?
$166/mo
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Old 02-19-2010, 08:34 PM   #18
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Ugh, something I need to look into before June when I become less than a full time student. I need to get a new insulin pump and stock up on supplies to mooch of my parents sweet plan as much as possible then.

But seriously, ugh. Lots of research.
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Old 02-20-2010, 10:44 AM   #19
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166/month for that plan is very not bad. Looks like everyone here has covered a lot of the points that need covering. Couple things though:

Not to ask for specifics, but do you take a lot of medications? If not, then you could probably get a plan with higher co-pays on prescriptions and that could lower your monthly. The prescription co-pays listed on that plan are actually pretty good for these days, and it is a nice low annual deductible.

Same deal for your office visits, the 20/primary and 30/specialists is pretty decent, so the question is do you go to lots of appointments? I think someone else already mentioned this but, the way that plan is set up your co-pays are pretty good, but if you go to lots of appointments each year you will be paying a lot since there is no deductible.

Choosing a plan is all about the long view. Balancing out your co-pays/deductibles with your monthly payment based on how often you go to the dr. For example, I rarely go to the doctor so my plan has relatively high co-pays/deductibles but a low monthly cost. And again, if you DO go to a lot of appointments, you want some kind of deductible on those or you can end up paying a LOT over the course of a year despite low co-pays.

Two more things you need to investigate. As others have mentioned, you need to get a network booklet from Keystone, or search for your current doctor on their website. Go Here and click on "Find Participating Doctors, Hospitals, and Ancillary Providers." With an HMO, you have to choose a primary doctor who belongs to their network, and whenever you see a specialist (also in network) you'll need a referral from your primary. Thankfully, this has gotten easier than it used to be as it is all electronic now. Although that doesn't mean they still don't forget to send em sometimes, they can send another one easily with a phone call.

Finally, I noticed you didn't list the emergency coverage. With any plan, you should see what kind of financial mess you can get in to if you have to go to the hospital. That info should have been listed with the other stuff you quoted in the original post.
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