If I go to dr. who is in my network

by tammy.fleeman » Fri Jun 18, 2010 04:49 am

If I go to dr. who is in my network and he is a provider and I have a ex: copay of 25.00 and the visit is 100.00 do I pay the balance after the bill is sumitted to ins (if I don't have a ded to meet) Or does the ins. pay the 75.00 to the dr. and I am only out the 25.00?

Total Comments: 22

Posted: Mon Nov 15, 2010 05:18 am Post Subject:

Well, I'm not familiar with the term "mediblue" -- in California we have Anthem Blue Cross (now owned by WellPoint as a for-profit entity) and, separately, Blue Shield (still a not-for-profit, once known as California Physician's Service), but you essentially understand it correctly.

A Medicare Advantage plan promises benefits to subscribers that are not less than what the Original Medicare Parts A & B provide. But most Medicare Advantage plans go well beyond that and provide services that Medicare might exclude from coverage (such as wellness exams).

The Medicare Advantage plans essentially receive a form of "capitation" from the Government (about $400 per month, maybe a little more -- I don't think I've ever seen the exact amount discussed/revealed). If they are well-subscribed by younger, healthier members, they can afford to provide more services to the seniors they insure.

Posted: Mon Nov 15, 2010 05:31 am Post Subject:

Be aware that with many policies your deductible will only be waived for the consultation received in the physician's office.

You may pay for any x-rays or labs you might need unless you have met your deductible.

Posted: Mon Nov 22, 2010 09:16 pm Post Subject:

Some policies will require that a deductible be met before the deductible comes into play.

I can't wait until they standardize medical insurance policies like they have for auto and homeowners insurance.

There are too may differences from policy to policy.

Posted: Tue Nov 23, 2010 05:29 am Post Subject:

Some policies will require that a deductible be met before the deductible comes into play.



That statement makes no sense. The deductible must normally be satisfied before any coinsurance takes effect.

I can't wait until they standardize medical insurance policies like they have for auto and homeowners insurance.



Although that's the hidden plot behind Obamacare -- to force all the commercial insurers out of business and leave us with the federal government in charge of rationing health care in a "single payer system", personally, I hope it never comes to pass.

I can't wait for the overhaul of the healthcare overhaul. I just hope it happens before 1-1-2014.

Posted: Tue Nov 23, 2010 07:22 am Post Subject:

You're right, that didn't make any sense. What I meant was "Some policies will require that a deductible be met before the copay comes into play."

However, I think you misunderstood the other statement. Standardizing health insurance has nothing to do with putting insurance companies out of business.

Standardization just means that the policies are much more alike than different.

Standardizing the policies won't in and of itself put the companies out of business.

Auto and homeowners insurance have been standardized for a long time.

You have the PAP for auto, the HO 3 for homeowners insurance. Medigap is standardized. Medicare Advantage and PDPs are fairly standardized.

I don't think that you should have to study each individual health insurance policy in order to be able to understand it when you've been in the business for 25 years.

Whenever someone asks me "how does the deductible work?" I have to answer with "on which policy?"

How are consumer to be expected to make the right decisions when the policies are so different and therefore so confusing?

Posted: Thu Nov 25, 2010 01:52 pm Post Subject:

I don't think that you should have to study each individual health insurance policy in order to be able to understand



No, I don't have to study each policy to understand it, but I have to study each policy to see if it is the proper coverage for the client's needs. "Standardizing" health insurance won't even come close to doing that. Group health insurance seeks to be a one-size fits all plan, and most folks know that it doesn't fit perfectly.

We already have 45 years of ACTUAL experience with a standardized plan of mass healthcare . . . it's called MEDICARE. The government said, "We're gonna take care of our old folks," and that's what they've done. Today, a single hospitalization of 150 days, utilizing all of one's "lifetime reserve" days, means an out of pocket expense of more than $45,000 for someone on "Original" Medicare. Those who are on "The Plan" know that it does not cover many of the things that are most important to them -- hearing aids, eyeglasses, routine orthopedic care for their arthritis, hospital "extras". Or long term care (100 days maximum, and only 20 paid for at 100%).

And on "Original" Medicare, until 2011, preventive care was NEVER covered. You know, go to the doctor once a year, whether you need to or not. Well, for 45 years, Medicare has said, "You get one "Welcome to Medicare" exam, and no annual checkups after that."

Obamacare now touts "free health care" -- in the sense that insurance companies have to provide "wellness" visits at no cost to the patient -- no deductibles, no copayments, no coinsurance, no out of pocket expense. What's "free" at the doctor's office, is only going to force premium payments up to pay for it. That's inevitable. And Obamacare was "sold" to the American people as the savior which was going to lower the cost of health care. It was NOT part of the "plan" that the AHIP, which represents the majority of health insurers today, thought it had worked out with Congress.

AHIP walked away from the negotiations thinking they had worked out a reasonable compromise. And that was their mistake, turning their back on Congress which stabbed them in the back before they got out of arm's reach.

When you force insurance companies to do things that cost money, don't give them the ability to recover that money (like raise premiums or trim benefits), essentially telling them they cannot continue to make a profit, you guarantee one thing: no more insurance companies. California did that in the 1990s when it "reformed Workers' Compensation." Killed off 1/3 of the insurers in the marketplace, drove rates to as high as $99 per $100 of payroll, and saddled the State of California with more than $2,000,000,000 of UNFUNDED LIABILITIES.

Why do we have the NFIP? the NCIP? the California Earthquake Authority? and similar "plans" -- because the insurance industry said, a long time ago, we can't cover those kinds of losses and earn a profit. So we won't even try. They exited the marketplace. Plenty of money on the table, but government requirements to cover claims in a way that cost money, not provided profits.

Insurance companies, slowly but surely, will not be able to cover the cost of Obamacare. The Democrats, who put all of this together behind closed doors and contrary to the needs or desires of the American people, had only one objective -- a single payer system of health care . . . the US Government.

They couldn't legitimately get the votes to pass the legislation, so they changed the legislation in a way that will lead to the collapse of the insured health care system that has been working and covering 80% or more of the American people for 60 years or more. When that happens, we will end up with the bottomless pit of a single-payer health care system.

If the combined $87,000,000,000,000 "shortfall" in Social Security and Medicare funding the Trustees first identified AND REVEALED a few years ago is only the tip of the iceberg, then Obamacare is the 2/3 below the waterline that we cannot see.

At least most of the American people cannot see it. They realize it's there, but they cannot explain/understand it. And that's why more than 70% are not in favor of the plan. Ask they why, and they cannot tell you, but they know in their hearts there's a problem.

Certainly, we needed some changes. We needed a better "plan" for the 40,000,000 - 50,000,000 who have no insurance. That could easily have been accomplished with a national health care program similar to the SGLI consortium. And if other people wanted in, they could have been accommodated as well.

But, no, Congress had to go and "overhaul" something already working on behalf of the other 280,000,000+ instead.

It was a BIG mistake, the real numbers we now know were suppressed, and we are watching that iceberg as it comes floating in this direction -- looking for the opportunity to punch a hole big enough to sink an entire civilization.

Allow me to continue to choose the plan that's right for me, to pay for it myself, and to remain separated from the Government's money. I am responsible for myself. I prefer that to the Government telling me what I must be given, and how it must be given to me, and at what cost. Let the Government meet its constitutional mandate: to provide for the common defense. Keep out the terrorists and the illegal aliens is mostly what they need to do today. And have some soldiers available to repel an attempted invasion by a foreign military force -- as the drafting fathers of the Constitution intended.

Standardized health care plans? The beginning of the end.

Posted: Thu Nov 25, 2010 02:41 pm Post Subject:

You made some good points, but none of them had much to do with what I posted.

If you have sold Med Sup or homeowners of auto insurance, you know that the policies have to be built on the same framework or form regardless of which insurer sells the policy.

Med Sup started out with 10 lettered policies and if you understood Mutual of Omaha's plan C you understood everybody else's plan C.

Most homeowner's policies are HO 3 forms and PAPs or personal auto policies are built on the same form.

This just make the policies easier to understand.

Yes, it is technically part of health care reform, but I think that it is one that is in consumers' best interest and has little downside.

Nails, screws and lightbulbs are standardized.

How annoying would it be if we had to weigh and measure each nail before we used it?

How annoying would it be if you had to buy take ten minutes to study the literature of each manufacturer to find the right bulb? It is only because they are standardized that we can glance at the lumens, watts and perhaps a few other bits of information in order to determine which policy to buy?

Posted: Sat Nov 27, 2010 01:39 am Post Subject:

You made some good points, but none of them had much to do with what I posted.



Really? You are longing for the day Health insurance is standardized like Med Supp, Homeowner's, et al. Rue the day that happens.

My post was entirely on target as to that. This was not a discussion of Med Supp -- which only covers those things the GOVERNMENT allows them to cover . . . you don't see hospital extras, wellness care (Obamacare not withstanding), orthopedic care, insulin for diabetics (other than those persons using a pump), dental, or . . . .

That's why I don't want, and most of the American public does not want, anything to do with Standardized Health Insurance.

You want readable contracts. Fine, I don't have an argument with that. We already have 12 NAIC "mandatory" and 11 "optional" provisions with "standardized language" that has been adopted to one extent or another in all 50 states, DC, Puerto Rico, Guam and the other territories. But "readable" contracts does not equal "Standardized" health insurance, which is what your post was calling for.

I didn't see you mention anything about life insurance. Any reason you would leave that alone while forcing everyone to live with the same health plan?

HMOs were once hated as the essence of SOCIALIZED medicine. But the free market has shown that they can provide broad services in competition with other HMOs. And PPOs take it a step further by allowing persons to leave the network (at additional cost) for whatever covered services they feel the need to obtain.

When we arrive at the SINGLE PAYER SYSTEM . . . all of that FREEDOM OF CHOICE we experience today -- at least those of us with some measure of health insurance -- will have evaporated and replaced with your beloved standardized health insurance.

That, my friend, will truly be SOCIALIZED MEDICINE. And those with any money at all will be forced to pay for those who choose not to work in order to freeload off the public trough.

Posted: Sat Nov 27, 2010 01:46 am Post Subject:

And as for "standardized" nails and lightbulbs . . .

What a non sequiter that is. We do not have ONE SIZE FITS ALL nails, and we have incandescent, fluorescent, compact fluorescent, halogen, sodium, mercury, LED, and carbon arc light bulbs. That they have "standardized" wattages or screw in bases doesn't mean you can screw a 120v 100W light bulb into a 220v socket and expect it to do more than burn itself out in an instant.

Cosmetics does not equal standardized. Med Supp is nothing more than "blemish cream" for the shoddy plan that Medicare has always been. And we still can't afford that plan after 45 years.

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