Deductibles and out of pocket maximums.... help me figure this out!

[StephandOwen]

My dr just sent me a letter outlining what I have left to pay him for this baby (the balance has to be paid by 34 weeks, I'm 32 weeks right now). So it says how much I have left to pay on my deductible, then it says how much my co-insurance is, and adding those together that's the total I still have left to pay (well, minus what I've already been paying).

So the question is.... each member of our family has a $500 deductible (dh, myself and ds). But we have a family deductible of $1000. We have already met our family deductible, even though I've only paid $43.xx into my personal deductible. But since we've already hit our family deductible, I shouldn't have to pay the rest of my deductible- right? Am I misunderstanding this? Shouldn't I have to pay just the co-insurance (20% of the bill)? The dr's office is saying I have to pay $457 ($500 deductible minus $43 that I've already paid of it) plus the co-insurance (20% of the bill).

We've called the dr's office and we've called the health insurance (united healthcare) and we just keep getting turned around in circles. Nobody seems to know the answer for some reason

[Sumada]

Isn't that nice when they run you in circles?? Grrrr...

From what I remember when our family was on the same health insurance plan through my hubby's work, once you hit the family deductible then you don't have to pay your individual deductible. Your insurance benefits should kick in since you have reached the family deduct. But all insurances are different, so I don't know for sure.

What happens when you reach your deductible? Then you pay 20% and the insurance pays 80%?

So again, I'm going off of memory here, but when my ds and myself and husband all had the same plan, which happened to be thru United Health too, we met our family deductible of $2000, then UH paid 80% of any medical bills and we had to pay 20%. (Up until we reached the $2000 deductible we had to pay for every medical expense. It was always billed through insurance first however). Then we had an out of pocket maximum of $5000.

Is your dr.s office asking for the money up front?

[StephandOwen]

This is actually my first big girl experience with insurance I had no insurance up until January of this year (and my ds was always on Medicaid up until January), so I've never had to deal with any of this.

From what I understand, we each have a $500 deductible, with a family limit of $1000. Once we hit the deductible (we've already hit the family deductible) then insurance pays 80% and we pay 20% up until we hit the maximum out of pocket expenses ($2000 per person or $5000 for the family). After that, insurance pays 100% (except co-pays, I believe).

At least, that's my understanding of how it works. I could be wrong!

Yes, the dr's office wants the entire payment up front (by 34 weeks into the pregnancy, which is August 31st for me). This payment only includes the dr's fees for all the office visits plus his delivery fees. The hospital bills are all separate. I've been paying on it since my second appointment so it's not so bad.

BUT, the problem is that they are saying that even though we've hit our family deductible, that I still have to hit my individual deductible. I only have $43.xx towards my deductible (because they haven't been counting the money I've already been paying to the dr as part of my deductible for some reason). Which means that that dr's office is saying I still owe $457ish before insurance kicks in and covers 80%.

Doing it their way, I owe another $541.39 right now. Doing it the way I think it should be done (with me not paying any more towards the deductible, since our family deductible has already been met) I would owe $84.51 and insurance would be paying the rest. That's a HUGE difference!

[FiveLittleMonkeys]

We also have a $500 per person/$1000 family deductible plan.  How it works is that the first two people who "get" to $500 meet the family deductible.  If additional family members have contributed towards their individual deductible (in your case, your $43), that amount becomes moot, because the family deductible has been met.

You should only be responsible for your 20%.  I would tell your OBs office that they need to call your insurance company, because according to the EOBs you've received, your husband and your son have fulfilled your families deductible, and therefore, your OBs office needs to re-calculate your account.

[StephandOwen]

Originally Posted by FiveLittleMonkeys 

You should only be responsible for your 20%.  I would tell your OBs office that they need to call your insurance company, because according to the EOBs you've received, your husband and your son have fulfilled your families deductible, and therefore, your OBs office needs to re-calculate your account.

Thanks! We did call them today and they said that the family deductible doesn't matter, I have to meet my individual deductible. It makes no sense at all- why would we have a family deductible if each member had to meet their own deductible anyway?! My dh was supposed to call the insurance company today, but he's still at work so I have no idea if he did. We have an appointment at the OB tomorrow morning so we'll see if we can get it all worked out somehow.

[sunflower.mama]

We too have the personal/family deductible thing, and I agree with the OP's interpretation of the policy.  What I don't get is why the OB hasn't billed the insurance co first?  Don't they bill the insurance co and get paid what insurance covers less your deductible?  And then bill you?  If they have done so, then your questions should go to the insurance co and not the dr.  What does the drs office know about what your family's expenses have been and whether you've met your deductible anyhow?

[StephandOwen]

I don't understand it either. They have not been billing the insurance company (except for things like the ultrasound and bloodwork- all those were billed to the insurance company). But for office visits they haven't billed anything. I've been paying some each time I've gone, which apparently has just gone into an account at the dr's office. What I've been paying did NOT go to the deductible. It appears on the statement I got as "payments/credits". They apparently did contact the insurance company (on 8/10 according to the paper I got today) to find out what I've paid towards my deductible so far.

So they have it broken down to what my deductible is ($500) minus what I've already paid towards the deductible ($43.12). Then they have the amount that insurance will allow them to bill for a vaginal birth ($1762.75). They have what my coinsurance is (20%, $352.55). They added my unmet deductible ($456.88) plus my coinsurance ($352.55). Then they subtracted the payments I've already made to the office ($268.04) to get the total ($541.39) that I still have to pay.

But from my understanding, since my family deductible has already been met, then they should have taken what the vaginal birth costs ($1762.75) and got my coinsurance from that (20%, $352.55). They should have subtracted the payments I already made to the office ($268.04) to get the total that I owe ($84.51).

[Sumada]

You should for sure check out why the OB office is not billing your insurance company for your regular prenatal visits. That seems weird to me. I never had to pay anything up front for my 2 ds births, so that seems strange too. After the birth of my first ds, when we had UH, the hospital /OB billed insurance first, and since I hadn't met my deductible, we had to pay some money, but it was a month or so after the birth that I got a bill.

And it may be you have to reach your individual deductible before the insurance pays 80%. From what one of the previous posters said, that may be the way your policy works.

[newbymom05]

I don't know, but when I was pregnant w/ DS2 my OB wanted the entire amount up front, even though that would mean I would overpay once I hit the deductible. They told me that they would bill the ins, and once we hit and ins reimbursed them they'd cut me a check for the overpayment. They basically said their way or the highway, and I liked the OB so we did it, and did get a check back after the delivery. It was really maddening, though. I kept every single bill from the doc, visits, u/s, tests, etc, and tracked it on a spreadsheet and could never make my numbers match what my insurance carrier had online. (United, btw). The doc said it would cost X, ins would pay Y and I'd owe Z and that's what happened, but to this day I have no idea how they worked those numbers . I think insurance co's are the BIGGEST scammy racket going.

Hmm, so I guess no advice, other than if you trust your doc's billing dept, if you do overpay you'll get it back, but only after the doc gets paid.

[StephandOwen]

Alright, we got it figured out. Woo! So at my appointment this morning when we went to check-out/pay I showed them a print-out from the insurance company's website showing that we had met our family deductible and asked why I had to continue paying the deductible. The girl looked really confused and said we shouldn't have to pay anything else towards the deductible. She looked at my acount from her computer screen and saw where they had been saying we still needed to pay towards the deductible, said that it was wrong and we were right and recalculated it. So we only owed the $84.51 instead of $541.39. Yippee!

Sumada- from my understanding, when an individual meets their deductible then that person starts the 80/20 part. So, for instance, my ds met his deductible long before dh or I did (gotta love weekly therapy sessions). So he had already moved towards insurance covering 80% and us covering 20% since his deductible was already met. When dh, ds and my deductibles added together reached the family deductible limit then ALL of us move to the 80/20. It doesn't make sense to make each individual hit their deductible if we have a family deductible limit. That's the point of the family deductible limit is so that we don't have to all hit our deductibles ($500 each, or $1500) before the 80/20 takes over. We just have to hit the family deductible limit ($1000) and then the 80/20 takes over for all of us.

What we have paid off is just the fees for the office visits and the dr's bill for delivery. We will still get the hospital bills after the baby is born.