this post was submitted on 04 Sep 2024
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No Stupid Questions

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Say my deductible is 1500 and I need a procedure that’s costs $1000 but my insurance will cover 50% before deductible. A few months before the procedure I managed to meet my deductible though does that mean they will cover 100% of it or the 50% still?

If possible try to explain like I’m five

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[–] [email protected] 8 points 1 month ago (5 children)

You need to know both your deductible and out of pocket maximum numbers. You’ve said your deductible is $1500. For the sake of this example let’s say your out of pocket max (OOP from now on) is $2500.

For simplicity, we’ll go with your insurance’s negotiated rate for the procedure is $1000*. Meaning at the end of the day you and your insurance combined will pay the hospital $1000.

Basically any bills up to $1500 for the year you pay 100%. Between $1500 and $2500 (or your OOP), insurance pays 50% and you pay 50%. Over $2500 insurance pays 100%.

Some examples to illustrate:

  1. You’ve paid $400 this year so far. You pay the full $1000: $400 + $1000 = $1400 which is less than your deductible of $1500
  2. You've paid $1000 so far this year. You pay $750 and insurance pays $250: $500 gets you to the $1500 deductible limit so you have to pay all that, plus you pay 50% of the remaining $500 bill = $250.
  3. You’ve paid $1700 so far. You pay $500 and insurance pays $500. $1700 + $500 = $2200 which is less than your OOP of $2500
  4. You’ve paid $2300 so far. You pay $200 and insurance pays $800. 50% of $1000 = $500 but $500 would put you over your OOP of $2500. $2500 - $2300 = $200. You pay $200 and insurance pays the rest.
  5. You’ve paid $2500 so far. Insurance pays $1000
  • If your insurance’s negotiated rate for the procedure is $1000, this means that’s what the hospital and insurance have agreed to pay. A lot of times you’ll see the hospital “charge” a larger number and then have an insurance “discount” but ignore this. It doesn’t factor into deductible or out of pocket maximum calculations.
[–] [email protected] 4 points 1 month ago (1 children)

Why is this all so convoluted and, seemingly, legal? Is this purposely convoluted to obfuscate illegal activity?

[–] [email protected] 5 points 1 month ago

I don’t know the actual answer. My theory is it’s this confusing so it’s hard for the general population to catch the mistakes. This allows insurance companies get out of paying as much as they’re supposed to. And hospitals don’t really care who does the paying, as long as they get paid

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