Lot's of confusion over these three terms.
Premium: The money you pay the insurance company every month. It's gone, and does NOT apply to either the deductible, the out-of-pocket max. (And, it does NOT go into your HSA...)
Deductible: The money you pay before your insurance company kicks in...
Out of Pocket Maximum: The MOST you'll pay in a calendar year, ASIDE from the Premium.
Now, to add to the loose ruck...A copay is just a fee to the Doc, or medical service provider, and also does NOT count within your deductible, or OOP MAX.
Sucks huh?
Showing posts with label copay. Show all posts
Showing posts with label copay. Show all posts
Wednesday, January 18, 2012
Saturday, February 16, 2008
Explaing Rugby (Health Insurance) to a Civilian
Ever try to explain Rugby to your Mom? Ruck, Maul, Line-out, Scrum, Touch, Knock-on, Grubber, 10m line, 22m line, 22m line kicking laws, Cut, Scissor, Skip, Loop, and, my favorite, TRY!
Health Insurance has it's own list of terms: Deductible, Co-pay, Co-insurance, Out-of-Pocket Maximum, Lifetime benefit, Mental Health limitations, preferred providers, in-network, out-of-network, authorization, premium, and, my favorite, CLAIM!
Over the three day weekend, I'll explain what each of these terms means. And, yes, you'll have that expression on your face as that friend of a friend who came out to watch a match. He, and you, will be completely fucking confused. Enjoy!
Deductible (Proper Definition): The portion of a claim not paid for by the insurance company.
Deductible (BMK's Definition): What your ass is gonna pay when you get hurt.
Example: An average ER visit is about $650. If your health plan's deductible is $500, you pay the hospital $500, and your insurance carrier will pay the $150, sorta. There's co-insurance too. Nice, huh?
In general, the higher the deductible, the lower the premium. Caution point: Your health plan might have a SEPARATE ER deductible, over and above the plan deductible.
Co-Pay (Proper Definition): A small fee you pay to see a doctor.
Co-Pay (BMK's Definition): A nickel-n-dime tactic to keep you from seeing a doctor.
Co-pays usually don't count towards your deductible (or your OOPMAX, see below). The theory is that if you pay $40 every time you visit a medical provider, you won't waste time with a headcold. The idea is cost sharing, share more of the cost with the insurance company, and you'll use services less.
Insurance companies get crushed by frequent medical visits for two reasons: The cost of services is increasing, and the paperwork is astounding. 600 Billion a year is spent in paper shuffling back and forth between providers and claims offices. Now the RAND Institute, has done a few studies on this, and yes, the higher the cost sharing between insurance company and patient tends to keep the patient away from the doctor.
Co-insurance (Proper Definition): A method to spread the cost of a loss among multiple parties.
Co-insurance (BMK's Definition): Holy shit, are you fucking kidding me? I've got to pay what?
Okay, now that you've paid your co-pay(s), and met your deductible, the remainder of the bill is split between you and the insurer. The split is typically 80/20, 80% them 20% you. (Read your policy, b/c it could be 70/30, or even 50/50 for out of network claims.)
So let's go back to the ER Example: $650 to get your head stitched. Let's hope you don't have a separate ER deductible, your main Deductible is $500, and your Co-insurance is 80/20.
$650 - $500 - $150 x 20% = $120 This is what your insurance provider will pay. How do those 300/month premiums feel now?
So your ER visit is $530 out-of-pocket to you.
[You best be pissed off by now]
Out-of-Pocket Maximum (Proper Definition): Also known as a stop-loss, it's the absolute maximum you'll pay in a year for medical expenses under your plan.
Out-of-Pocket Maximum (BMK's Definition): The final squeezing of the last drop of blood from your lifeless body.
Remember the concept of cost sharing. If you and the insurer share costs, you're less likely to use the services, and thus save the insurer money. The insurer can't control health care costs, so they control your cost sharing.
So final Example before I go work-out. Let's say a prop falls on you, and you tear you acl. Ambulance ride, ER, MRI, surgery, and physical therapy. Let's say all the bills come to $10,000.
You've got a $500 deductible plan, 75/25 with a OOP Max of $3500, like Blue Shield's PPO 500 here in CA. I'm adding the $100 ER Deductible, and the $250 out patient surgery deductible that don't go towards your OOP Max. [Oh yeah, did I mention that this shit is complicated?]
What YOU PAY:
$500 + $100 + $250 + $9,150 x 25% = $850 + $2,287.50 = $3,137.50
This is does NOT include your premiums. This plan for me (I'm 37) is $459 a month: $5508
So for this year you spent over $8600 on health care. Can you afford that?
Even better, you still have over $1200 to go to reach your OOP Max for the year.
Now I have an HSA plan, $4000 Deductible, and an Accident Medical Plan that pays $5000 per year, with a $100 deductible per incident:
What I'd pay:
$100
Add to that my premiums: $96/month for the HSA plan, and $45/month for the AMC: $1692
Remember, my plan has no co-pay, no co-insurance, no OOP Max. I spend $4000 and I'm 100% covered after that. My Accident Medical Plan pays for all the stuff my insurance doesn't minus a $100 deductible.
That's a difference of $6,853.50. And I can put back $2900 into an HSA and deduct that money from my taxable income!
Do you NOW understand why I promote HSA plans and AMC plans?
Now here's the downside of my way of doing things. If I don't get hurt, but I need to see a doctor, I pay whatever the doctor charges. This could be upwards to $200. I pay for prescriptions outright, unless they're on the Walmart list. Also, if I get a debilitating disease, I must come up with the the $4,000 every year for the deductible, not including the premiums, to keep my coverage. This is about risk analysis. I'm more likely to get hurt playing than get sick, so I chose a plan combination that covers injuries, not long term illness. I've made a choice.
I chose simplicity. And isn't Rugby essentially a simple game. Create space for the ball carrier. Simplify the rules of insurance, and health care might become as pretty as scoring tries!
Health Insurance has it's own list of terms: Deductible, Co-pay, Co-insurance, Out-of-Pocket Maximum, Lifetime benefit, Mental Health limitations, preferred providers, in-network, out-of-network, authorization, premium, and, my favorite, CLAIM!
Over the three day weekend, I'll explain what each of these terms means. And, yes, you'll have that expression on your face as that friend of a friend who came out to watch a match. He, and you, will be completely fucking confused. Enjoy!
Deductible (Proper Definition): The portion of a claim not paid for by the insurance company.
Deductible (BMK's Definition): What your ass is gonna pay when you get hurt.
Example: An average ER visit is about $650. If your health plan's deductible is $500, you pay the hospital $500, and your insurance carrier will pay the $150, sorta. There's co-insurance too. Nice, huh?
In general, the higher the deductible, the lower the premium. Caution point: Your health plan might have a SEPARATE ER deductible, over and above the plan deductible.
Co-Pay (Proper Definition): A small fee you pay to see a doctor.
Co-Pay (BMK's Definition): A nickel-n-dime tactic to keep you from seeing a doctor.
Co-pays usually don't count towards your deductible (or your OOPMAX, see below). The theory is that if you pay $40 every time you visit a medical provider, you won't waste time with a headcold. The idea is cost sharing, share more of the cost with the insurance company, and you'll use services less.
Insurance companies get crushed by frequent medical visits for two reasons: The cost of services is increasing, and the paperwork is astounding. 600 Billion a year is spent in paper shuffling back and forth between providers and claims offices. Now the RAND Institute, has done a few studies on this, and yes, the higher the cost sharing between insurance company and patient tends to keep the patient away from the doctor.
Co-insurance (Proper Definition): A method to spread the cost of a loss among multiple parties.
Co-insurance (BMK's Definition): Holy shit, are you fucking kidding me? I've got to pay what?
Okay, now that you've paid your co-pay(s), and met your deductible, the remainder of the bill is split between you and the insurer. The split is typically 80/20, 80% them 20% you. (Read your policy, b/c it could be 70/30, or even 50/50 for out of network claims.)
So let's go back to the ER Example: $650 to get your head stitched. Let's hope you don't have a separate ER deductible, your main Deductible is $500, and your Co-insurance is 80/20.
$650 - $500 - $150 x 20% = $120 This is what your insurance provider will pay. How do those 300/month premiums feel now?
So your ER visit is $530 out-of-pocket to you.
[You best be pissed off by now]
Out-of-Pocket Maximum (Proper Definition): Also known as a stop-loss, it's the absolute maximum you'll pay in a year for medical expenses under your plan.
Out-of-Pocket Maximum (BMK's Definition): The final squeezing of the last drop of blood from your lifeless body.
Remember the concept of cost sharing. If you and the insurer share costs, you're less likely to use the services, and thus save the insurer money. The insurer can't control health care costs, so they control your cost sharing.
So final Example before I go work-out. Let's say a prop falls on you, and you tear you acl. Ambulance ride, ER, MRI, surgery, and physical therapy. Let's say all the bills come to $10,000.
You've got a $500 deductible plan, 75/25 with a OOP Max of $3500, like Blue Shield's PPO 500 here in CA. I'm adding the $100 ER Deductible, and the $250 out patient surgery deductible that don't go towards your OOP Max. [Oh yeah, did I mention that this shit is complicated?]
What YOU PAY:
$500 + $100 + $250 + $9,150 x 25% = $850 + $2,287.50 = $3,137.50
This is does NOT include your premiums. This plan for me (I'm 37) is $459 a month: $5508
So for this year you spent over $8600 on health care. Can you afford that?
Even better, you still have over $1200 to go to reach your OOP Max for the year.
Now I have an HSA plan, $4000 Deductible, and an Accident Medical Plan that pays $5000 per year, with a $100 deductible per incident:
What I'd pay:
$100
Add to that my premiums: $96/month for the HSA plan, and $45/month for the AMC: $1692
Remember, my plan has no co-pay, no co-insurance, no OOP Max. I spend $4000 and I'm 100% covered after that. My Accident Medical Plan pays for all the stuff my insurance doesn't minus a $100 deductible.
That's a difference of $6,853.50. And I can put back $2900 into an HSA and deduct that money from my taxable income!
Do you NOW understand why I promote HSA plans and AMC plans?
Now here's the downside of my way of doing things. If I don't get hurt, but I need to see a doctor, I pay whatever the doctor charges. This could be upwards to $200. I pay for prescriptions outright, unless they're on the Walmart list. Also, if I get a debilitating disease, I must come up with the the $4,000 every year for the deductible, not including the premiums, to keep my coverage. This is about risk analysis. I'm more likely to get hurt playing than get sick, so I chose a plan combination that covers injuries, not long term illness. I've made a choice.
I chose simplicity. And isn't Rugby essentially a simple game. Create space for the ball carrier. Simplify the rules of insurance, and health care might become as pretty as scoring tries!
Saturday, February 02, 2008
HSA Downsides...same in Rugby as kicking for position.
You've got to play Rugby in the opponents end of the pitch. Unless you're Carlos Spencer. ;)
The downside of kicking into your opponents end is that you typically lose possession. A strong lineout or a pressure defense can usually turn the ball back over to you.
Rugby players will use more health services on average than civilians. Rugby is an injury-prone sport. But RuckingInsurance.com still insists HSA policies are the best for Rugby Players. Still, you need to know the downsides, the gaps in the defense.
Here are the downsides to HSAs:
1. You're all out-of-pocket until you hit the deductible.
Basic health expenses are on your ass. Pick a deductible you can handle, or supplement with an AMC plan. That means no co-pay for doctor or ER visits. No R/x benefit either, but Walmart can sort that out, usually for only $4.
2. You can't have an HSA without a High-Deductible HSA qualified plan.
This part sucks. So, for the Insurance Lobby to sign off on tax-deductible health care, they needed a piece of the pie. Bastards. This affects players with major injuries, like shoulder or knee reconstruction. This could prevent you from getting insurance, thus no HSA. Ironically, the people who need tax-free healthcare the most can't get it. You listening, you politicians?
3. It's up to you to track your health expenses.
If you don't open an HSA account, you're stuck creating the Tax Schedule yourself. Could be a major pain in the ass, since you might not know all that's on, or NOT on the list. Get a CPA to check it, which, of course, costs you more money.
4. Frickin' pointless if you don't fully fund it.
No, you don't have to fund it fully($5800 for a family, $2900 for a individual). But you're not going to have Medicare when you retire at 65. You'll need an HSA nest egg for either big procedures and/or Long Term Care. Sucks. Get over it.
You play Rugby. Props fall on you. Fullbacks who know fuck-all about forward play shirt tackle you to the hard deck. Sometimes you get injured.
You need your own insurance. You must take responsibility for your own healthcare. No one will do it for you. Yes, it seems you're kicking away possession, but a quick turnover inside the 22m, and it's Try-City Baby!
The downside of kicking into your opponents end is that you typically lose possession. A strong lineout or a pressure defense can usually turn the ball back over to you.
Rugby players will use more health services on average than civilians. Rugby is an injury-prone sport. But RuckingInsurance.com still insists HSA policies are the best for Rugby Players. Still, you need to know the downsides, the gaps in the defense.
Here are the downsides to HSAs:
1. You're all out-of-pocket until you hit the deductible.
Basic health expenses are on your ass. Pick a deductible you can handle, or supplement with an AMC plan. That means no co-pay for doctor or ER visits. No R/x benefit either, but Walmart can sort that out, usually for only $4.
2. You can't have an HSA without a High-Deductible HSA qualified plan.
This part sucks. So, for the Insurance Lobby to sign off on tax-deductible health care, they needed a piece of the pie. Bastards. This affects players with major injuries, like shoulder or knee reconstruction. This could prevent you from getting insurance, thus no HSA. Ironically, the people who need tax-free healthcare the most can't get it. You listening, you politicians?
3. It's up to you to track your health expenses.
If you don't open an HSA account, you're stuck creating the Tax Schedule yourself. Could be a major pain in the ass, since you might not know all that's on, or NOT on the list. Get a CPA to check it, which, of course, costs you more money.
4. Frickin' pointless if you don't fully fund it.
No, you don't have to fund it fully($5800 for a family, $2900 for a individual). But you're not going to have Medicare when you retire at 65. You'll need an HSA nest egg for either big procedures and/or Long Term Care. Sucks. Get over it.
You play Rugby. Props fall on you. Fullbacks who know fuck-all about forward play shirt tackle you to the hard deck. Sometimes you get injured.
You need your own insurance. You must take responsibility for your own healthcare. No one will do it for you. Yes, it seems you're kicking away possession, but a quick turnover inside the 22m, and it's Try-City Baby!
Wednesday, January 30, 2008
How many beers does First Dollar Coverage cost?
Does your Rugby Club buy your boots? What about headgear, shoulder pads, sliders for under your shorts?
No? They don't pay for that stuff?
Then why the Hell do you think your Health Insurance should pay for R/x and doctor visits?
Health Insurance should pay the bills for when you get sick. You're insuring your health. But since Americans got sold on the HMO-based copay, it's become an expected entitlement. This paradigm must change.
Realize that if you insist on buying first dollar coverage, then your aggregate lifetime maximum will be relatively low. Chronic ailments cost insurance companies, not knee reconstructions. Chronic ailments require lots of drugs and doctor's visits. Such treatments add up.
I'll extend the metaphor a bit. If your club supplied EVERYTHING for you, how much would your dues be? 5 times? 10?
Buy your own boots. See an MD on your own dime. Buy your own rugby health insurance. Grow up.
No? They don't pay for that stuff?
Then why the Hell do you think your Health Insurance should pay for R/x and doctor visits?
Health Insurance should pay the bills for when you get sick. You're insuring your health. But since Americans got sold on the HMO-based copay, it's become an expected entitlement. This paradigm must change.
Realize that if you insist on buying first dollar coverage, then your aggregate lifetime maximum will be relatively low. Chronic ailments cost insurance companies, not knee reconstructions. Chronic ailments require lots of drugs and doctor's visits. Such treatments add up.
I'll extend the metaphor a bit. If your club supplied EVERYTHING for you, how much would your dues be? 5 times? 10?
Buy your own boots. See an MD on your own dime. Buy your own rugby health insurance. Grow up.
Monday, January 28, 2008
$4 Prescriptions at Walmart...Rugby Gods be Praised
The two biggest objections I get when presenting an HSA-qualified plan:
1. I do NOT have a doctor visit co-pay?
2. I have to pay FULL price for prescriptions?
First one is easy. Go to a minor emergency medical center.
Second one....WALMART!
So Walmart has decided to charge $4 for a 30 day supply of various drugs. Why? Cuz you ain't gonna just go into Walmart and merely fill a prescription.
You'll need to buy athletic tape, electric tape, gatorade, water, and maybe even field paint for the pitch.
Rugby Players CAN go to a doctor. Rugby Players CAN pay for prescriptions. The idea that we don't have access to healthcare in the USA is bullshit.
Hell, I can't get a pint of Guinness for less than $4.50!!!!
1. I do NOT have a doctor visit co-pay?
2. I have to pay FULL price for prescriptions?
First one is easy. Go to a minor emergency medical center.
Second one....WALMART!
So Walmart has decided to charge $4 for a 30 day supply of various drugs. Why? Cuz you ain't gonna just go into Walmart and merely fill a prescription.
You'll need to buy athletic tape, electric tape, gatorade, water, and maybe even field paint for the pitch.
Rugby Players CAN go to a doctor. Rugby Players CAN pay for prescriptions. The idea that we don't have access to healthcare in the USA is bullshit.
Hell, I can't get a pint of Guinness for less than $4.50!!!!
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