# Help me understand my health insurance **URL:** \ **Category:** Factual Questions\ **Created:** [July 12, 2005, 7:12pm UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222 "2005-07-12T19:12:15Z")\ **Posts on this page:** 12\ **Page:** 1
**Author:** ![bouv](https://avatars.discourse-cdn.com/v4/letter/b/bc8723/32.png) [@bouv](https://boards.straightdope.com/u/bouv)\ **Post date:** [July 12, 2005, 7:12pm UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222/1 "2005-07-12T19:12:15Z")
Alright, being a complete idiot when it comes to anything financial, I really have no idea how much I pay when I have to go to the doctor, like I did last week. I looked at the website that gives me all my info, and basically almsot everything (ER visit, office appointment, surgery, etc…) says that the plan pays 70% after a $200 deductable. OK, I understand the 70% part…I have to apy 30% of whatever the hospital bills my inusrance, but what does thast deductable part mean? Does that mean that i have to pay that first $200 myself no matter what? Or does it mean that I need to ahve paid at least $200 into my health insurance this year through my monthly payments? ---
**Author:** ![Hello\_Again](https://avatars.discourse-cdn.com/v4/letter/h/85e7bf/32.png) [@Hello\_Again](https://boards.straightdope.com/u/Hello_Again)\ **Post date:** [July 12, 2005, 7:18pm UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222/2 "2005-07-12T19:18:19Z")
$200 deductible means you pay the first $200 of your expenses, then the percentage system takes over. Usually the deductible is yearly, not “per visit” so if you use up your deductible on one visit, you don’t pay into it again till next plan year. ---
**Author:** ![Hello\_Again](https://avatars.discourse-cdn.com/v4/letter/h/85e7bf/32.png) [@Hello\_Again](https://boards.straightdope.com/u/Hello_Again)\ **Post date:** [July 12, 2005, 7:19pm UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222/3 "2005-07-12T19:19:29Z")
However, sometimes routine office visits are separated out from other expenses… in which case you might have a “co-pay” that you pay, and then the insurance takes care of the rest. ---
**Author:** ![bouv](https://avatars.discourse-cdn.com/v4/letter/b/bc8723/32.png) [@bouv](https://boards.straightdope.com/u/bouv)\ **Post date:** [July 12, 2005, 7:29pm UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222/4 "2005-07-12T19:29:44Z")
OK, so I was basically right with my first guess, with the addition of I pay the first $200 for every covered medical expense for that year, adn then it takes over. Man, I wish I lived in an area that was considered part of the insurances providing network, I’d have 90% payment after a $100 deductable. Argh, lousy insurance, it screws you at every corner! ---
**Author:** ![Hello\_Again](https://avatars.discourse-cdn.com/v4/letter/h/85e7bf/32.png) [@Hello\_Again](https://boards.straightdope.com/u/Hello_Again)\ **Post date:** [July 12, 2005, 7:35pm UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222/5 "2005-07-12T19:35:38Z")
> [@bouv](#): > > OK, so I was basically right with my first guess, with the addition of I pay the first $200 for every covered medical expense for that year, adn then it takes over. Just to clarify: You pay the first $200, period. Not the first $200 of each covered expense. Once you’ve fulfilled the deductible in one year, you do not pay it again until the next year. ---
**Author:** ![bouv](https://avatars.discourse-cdn.com/v4/letter/b/bc8723/32.png) [@bouv](https://boards.straightdope.com/u/bouv)\ **Post date:** [July 12, 2005, 7:49pm UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222/6 "2005-07-12T19:49:16Z")
> [@Hello Again](#): > > Just to clarify: You pay the first $200, period. Not the first $200 of each covered expense. Once you’ve fulfilled the deductible in one year, you do not pay it again until the next year. Yeah, that’s what I meant, I jsut phrased it completly, 100%-ly wrong. :smack: ---
**Author:** ![ouryL](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/ouryl/32/6067_2.png) [@ouryL](https://boards.straightdope.com/u/ouryL)\ **Post date:** [July 12, 2005, 7:54pm UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222/7 "2005-07-12T19:54:26Z")
Here, it’s $600. ☹ ---
**Author:** ![Mr.Blue\_Sky](https://avatars.discourse-cdn.com/v4/letter/m/d26b3c/32.png) [@Mr.Blue\_Sky](https://boards.straightdope.com/u/Mr.Blue_Sky)\ **Post date:** [July 12, 2005, 8:01pm UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222/8 "2005-07-12T20:01:07Z")
Insurance biller piping in: As for the 70/30 part: if the insurance co has a contract with the facility, then it’s 70% of the contracted rate, not the total charges. This can amount to tons of money. Make sure you go to the facility/facilities listed by your insurance company. If the facility you choose is not listed (except in emergency cases), you may end up paying the ENTIRE bill. Check your policy!! ---
**Author:** ![WhyNot](https://avatars.discourse-cdn.com/v4/letter/w/c77e96/32.png) [@WhyNot](https://boards.straightdope.com/u/WhyNot)\ **Post date:** [July 12, 2005, 8:13pm UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222/9 "2005-07-12T20:13:41Z")
Bwahaahaahaa! [/bitter laugh] **$2500** deductible. 80% coverage after that $5500 out-of-pocket maximum. (The total amout we have to pay each year if we have a catastrophic thing happen, like we did this year. After we’ve paid this much (our 20%s), we don’t pay any more until next year. And our premiums (monthly payment) for a family of 4 is more than $700 every month. Goddam private health insurance. :mad: ---
**Author:** ![bouv](https://avatars.discourse-cdn.com/v4/letter/b/bc8723/32.png) [@bouv](https://boards.straightdope.com/u/bouv)\ **Post date:** [July 12, 2005, 9:04pm UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222/10 "2005-07-12T21:04:14Z")
> [@Mr. Blue Sky](#): > > Insurance biller piping in: > As for the 70/30 part: if the insurance co has a contract with the facility, then it’s 70% of the contracted rate, not the total charges. This can amount to tons of money. Make sure you go to the facility/facilities listed by your insurance company. If the facility you choose is not listed (except in emergency cases), you may end up paying the ENTIRE bill. > > Check your policy!! AFAIK, my insurance for doctor’s office visits, emergency visits, lab work, x-rays, and most other things covers every hospital in the US. I get better coverage for hospitals it is contracted with, but still get coverage for out of area hospitals. ---
**Author:** ![jacobsta811](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/jacobsta811/32/2893_2.png) [@jacobsta811](https://boards.straightdope.com/u/jacobsta811)\ **Post date:** [July 13, 2005, 5:26am UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222/11 "2005-07-13T05:26:50Z")
Yeah, but you are missing a BIG difference between “In Network” and “Out of Network” hospitals, doctors, etc- the difference between the “Cash Rate” and the “In Network PPO Rate”. To use my own situation as an example, my son’s NICU bill for 2005 was shown as $95,000. The negotiated rate that Blue Cross had to pay was about $15,000. If the copay was 90% in network, 70% out of network, I owe $1500 for the in network and $28,500 for the out of network - remember that you don’t get the “Negotiated Rate” out of network. ---
**Author:** ![WhyNot](https://avatars.discourse-cdn.com/v4/letter/w/c77e96/32.png) [@WhyNot](https://boards.straightdope.com/u/WhyNot)\ **Post date:** [July 13, 2005, 10:03am UTC](https://boards.straightdope.com/t/help-me-understand-my-health-insurance/312222/12 "2005-07-13T10:03:19Z")
> [@jacobsta811](#): > > Yeah, but you are missing a BIG difference between “In Network” and “Out of Network” hospitals, doctors, etc- the difference between the “Cash Rate” and the “In Network PPO Rate”. To use my own situation as an example, my son’s NICU bill for 2005 was shown as $95,000. The negotiated rate that Blue Cross had to pay was about $15,000. If the copay was 90% in network, 70% out of network, I owe $1500 for the in network and $28,500 for the out of network - remember that you don’t get the “Negotiated Rate” out of network. \*\*bouv \*\*isn’t discounting it at atll. S/he doesn’t live near network providers, apparantly: > [@bouv](#): > > Man, I wish I lived in an area that was considered part of the insurances providing network, I’d have 90% payment after a $100 deductable. Argh, lousy insurance, it screws you at every corner! So **bouv** ’s out-of-network rate is 70/30, in-network rate is 90/10. For a big bill, it might be worth it to travel quite a ways, though. We had an infant in NICU for over three months this year. I haven’t totalled her bills up, but it’s well over $250,000. at the out-of-network rate. Seems as though the in-network deal has the insurance paying roughly half of that. These “in-network” deals have me wondering if this oft-repeated notion that the insured are paying for the uninsured’s health care is correct. If I didn’t have insurance, I’d be on the hook for the whole $250,000. Yet, with insurance, the hospital only gets $125,000. So, are they just assuming that the uninsured never pay, or declare bankruptcy or something? Because it seems they should get MORE money from the uninsured in this scheme.