Insurance Questions

bearsandbeets7 · March 2016

Our insurance covers 60/40. Insurance pays 60% and we pay 40%. My question is does the 40% that we pay go towards our deductible or just the OOP max? I feel like this is an extremely stupid question but thinking back to when I spoke with my OBs patient coordinator or whatever she is, she said she included some of my deductible in our payments that we're making. This is all so confusing. Also I don't really understand having a deductible if we also have an OOP max, what's the point?

Also there has to be others with questions on insurance coverage so this thread can be used for that as well!

mmclark10 · March 2016

I would check with the insurance company to be sure, but generally the deductible is an amount you pay out of pocket and once you reach that amount insurance kicks in more of a percentage. The OOP max is the absolute total you pay before insurance covers 100%.

For example, my family deductible is about 2,600 and after we pay that amount ourselves out of pocket, insurance then pays 75% of anything billed to us after that and we only pay 25% of those billed amounts. Once we reach our OOP max (6,750) then insurance covers 100%.

1faceinacrowd · March 2016

Here's how it typically works:
-First, you pay your deductible. You are responsible for 100% of charges until that deductible is met.
-Next, you start to pay your coinsurance. In your case, that's 40% of the charges. Both your deductible AND your coinsurance go toward the OOP max. Once your OOP is met, your responsibility is 0%.

For example. If you have a 500 deductible, 60/40 coinsurance, and a $2000 OOP, you will pay $500 of your charges. Then, you'll pay 40% until you've reached another $1500. Then, insurance will pick up the rest of your covered charges.

(I have worked in the insurance industry most of my career. Happy to answer any questions I can!)

texasmama2014 · March 2016

Just a little tip, didn't work for me last time I delivered, but it has in the past for other medical bills. Contact the person billing you (I got bills from the hospital and the anesthesiologist and the hospital), and see if you can get a discount if you pay in full. It worked for a few other medical bills I had in the past, but not for my labor/delivery/epidural costs, but it never hurts to ask!

1faceinacrowd · March 2016

Oh yes, I agree with @texasmama2014! Just make sure you contact them as soon as you get a bill! In the two billing offices I've worked for, we were only allowed to give a "paid in full discount" if they were still on their first billing cycle. Once you've received 2 or more statements without making payment, they're less likely to work with you.

tmk0325 · March 2016

I'm a FTM here and since the thread was started with insurance questions I thought I would post mine here too if that's ok. I'm pregnant with twins and am currently on a plan through the marketplace that I was able to get on during open enrollment in Nov. My new job doesn't offer insurance, so I am staying on it.. The question however is when do I need to put my babies (twins) on it? Is this something you do before they are born? Is it a grace period after they are born? I just want to make sure we are all covered and I can shop around if I need too. Thanks!

jamiesc58 · March 2016

@tmk0325 I could not add our baby to the insurance until after she was born. Then it back dated to the day she was born. It will be the same with this one. I am not positive if it is the same with all insurances but I would assume you can't add them until they are born.

Bookhousegirl · March 2016

Yeah, they usually back date it as long as you call within a week or so of when the babies are born. I did this through DH's hr person, but I would call your specific plan to find out when you need to call.

mmclark10 · March 2016

@tmk0325 With my last job's insurance and with my current one, it was a 60 day period after the baby was born to add to the plan.

tmk0325 · March 2016

Great, thanks ladies!! I'll call and ask.

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