How does health coverage work in the US?

[sys49152]

..just finished reading this thread : http://gstwins.com/forum/viewtopic.php?t=21764, and was wondering how health coverage works in the US.  Does this sound about right :

The company you work for covers you by applying a monthly fee or as part of the standard benefits, and that coverage usually extends to all dependents (and spouse if the spouse does not have a separate plan).  And usually, as a student, if your parents have coverage, you're also covered up to some maximum age (45 year old student need not apply)?

And if your company doesn't provide coverage, you can purchase it from one of many vendors.

Also, if you're in an accident and you're taken to a hospital AND you have some standard coverage, would that (in most cases) cover all expenses for the emergency -- ambulance, treatment and a night or two chez St. Michael's medical center, or whatever.  I guess any follow up treatment may require you to discuss with your health provider (a list of available specialists/hospitals you can go for a follow up)?

[Phaedrus]

Yeah, you got the basic idea. Not everone here gets health insurance though. We also have things like Medicare and Medicaid to help with the elderly and  low-income. But anyways, let's use my as an example for health insurance. I work for New York state, and I am unmarried with no kids, so I have 'individual' health insurance. If I were married or had kids, I could have hem covered under another (more expensive to me) plan. Say I need a check up or a have a hospital visit, and they typically charge $90 per visit. If they accept my insurance, then I pay a "co-pay", which is a small amount that I am responsible for. In my case, it is $10. The insurance company will pay the rest of what they "allow". Say they only allow $70 per visit. In that case, I am billed $70; I pay the $10 co-pay and he insurance pays $60. If the doctor/hospital does NOT accept my insurance, then I either pay the $90 they ask for or find a different place that DOES accept the insurance I have. Most places will accepy the insurance since they figure some money is better than no money, I guess  :dunno:

[sys49152]

Phaedrus, thanks.  Makes sense.  But how about in the case where you're in an accident and the emergency crew takes you to the closest hospital for treatment.  Would those types of trips be covered, or does that still depend on which hospitals your insurance coverage is accepted at?  I was hoping that there might be some sort of "emergency clause" or something, meaning even it the hospital wasn't on the list of covered locations, the insurance company might make an except and pay the required amount in this case.

[Gisser]

Healthcare plans have so many conditions, rules, exceptions that they are difficult to fully comprehend and remember.    

Personally, I'm enrolled under one of the Blueshield/Bluecross individual plans.  Monthly premiums are $120 with a $5000 annual deductible and $2000,000 lifetime benefit.  

There is no deductible for an accident or injury.  Refer to opening sentence with respect to coverage for follow-up treatments.  

It did not sound as if 97gs500e was covered by insurance so he may pay out of pocket or if he is destitute the hospital may eventually write-off the debt (hospitals often receive reimbursements from state govt.).

[indestructibleman]

when i broke my heel i discovered that the coverage i had through school only covered a certain amount per hospital visit.

after the x-ray showed there was a break, they did a ct scan to make sure there were no bone fragments that would require surgery.

anyway, this went over the maximum per visit amount.  honestly can't remember how much (it's been a long time, and my parents covered it for me), but i think it was near $1000 that they ended up paying.


-will

[Gisser]

But how about in the case where you're in an accident and the emergency crew takes you to the closest hospital for treatment.  Would those types of trips be covered, or does that still depend on which hospitals your insurance coverage is accepted at?

My insurance would only cover 60% at a non-preferred medical facility.  

[Phaedrus]

.. if he is destitute the hospital may eventually write-off the debt (hospitals often receive reimbursements from state govt.).

Yeah, there are a lot of rukles/regulations/fine print, etc. Before I had health insurance coverage through work, I had to go to the Emergency Room for something, and the bill ended up being about $450. I had no way of paying it; they had me fill out some Hill paperwork (I think it was Hill Burton or something like that) and waived the fee.

[pandy]

My insurance would only cover 60% at a non-preferred medical facility.  

Even for an emergency? If it's an emergency, my plan will pay as if I were at a preferred hospital...  :dunno:

[banner]

It doesn't.

[yamahonkawazuki]

youre lucky, i was "discontinued"from a medicaid program. i am an insulin dependent diabetic. basically, unless i find insurance i can afford, i will be dead within a years time  :x

[un1261]

Just to throw in another aspect of the insurance game.

If you injuried while on the clock, workman's comp. takes over the whole bill. You pay nothing. My last visit to the hospital was a total of $3500.00.
This did not include an ambulance ride, I drove the guy to the hospital, just emegerancy room and two stitches in his head. They gave him a shot of something and two pills for pain. no x-rays. I think they charged us for sitting in the waiting room...3 hours.

Now who's the crook, the insurance companies or the hospitals?

[sys49152]

Even for an emergency? If it's an emergency, my plan will pay as if I were at a preferred hospital...

So I guess it really depends on the fine print and plan -- some plans do cover you in case of an emergency when you have really no choice which hospital you go to.  Others cover some portion of it as Gisser mentioned (60% of it).  That's really not too bad, unless the emergency is an emergency by-pass procedure.. even 40% would be several thousands of dollars I'd guess.

i was "discontinued"from a medicaid program

?  How can you be kicked out of a program, unless you lied on the initial application, or perhaps abused it in some way?  Or perhaps you need to re-apply in some way every year or few years, and if the criteria changes, the option to not renew exists?  I thought medicare and medicaid would cover you when all else fails.  The coverage may not be as good as some "premium" health insurance providers, but it was at least available.

[callmelenny]

?  How can you be kicked out of a program, unless you lied on the initial application, or perhaps abused it in some way?  Or perhaps you need to re-apply in some way every year or few years, and if the criteria changes, the option to not renew exists?  I thought medicare and medicaid would cover you when all else fails.  The coverage may not be as good as some "premium" health insurance providers, but it was at least available.

Medicaid is funded through a complex scheme of federal and state monies. Coverage criteria vary from state to state and can change within a state from year/year. Many "working poor" make too much money to qualify but not nearly enough to afford decent  insurance. The definitions of who qualify are complicated and there are many lawyers that specialize in arguing your case for you.

[yamahonkawazuki]

Even for an emergency? If it's an emergency, my plan will pay as if I were at a preferred hospital...

So I guess it really depends on the fine print and plan -- some plans do cover you in case of an emergency when you have really no choice which hospital you go to.  Others cover some portion of it as Gisser mentioned (60% of it).  That's really not too bad, unless the emergency is an emergency by-pass procedure.. even 40% would be several thousands of dollars I'd guess.

i was "discontinued"from a medicaid program

?  How can you be kicked out of a program, unless you lied on the initial application, or perhaps abused it in some way?  Or perhaps you need to re-apply in some way every year or few years, and if the criteria changes, the option to not renew exists?  I thought medicare and medicaid would cover you when all else fails.  The coverage may not be as good as some "premium" health insurance providers, but it was at least available.

. nope our illustrious governor, decided to trim the state budget, which included cutting me, and 400k others out of the tenncare program (state version of medicaid.) plus i find out i cant appeal, cause, i either have to be on dis-ability, female, be younger than 19, be crazy (documented), hell i dont qualify for state medicaid :x . hmmm what to do, hell if i could go to canada, id be there lol :dunno:. basically for me to get back on it, i need to qualify for fed. medicaid, or have a disability :dunno:

[octane]

The short answer is that the system doesn't work. At least not as well as it should and it leaves many people without adequate coverage.

In my case I pay $480 per month to cover my family through my employer. To answer the emergency question, most insurance will cover MOST of your emergency room bills. My ER copay is $50.00. But as a few people mentioned, the fine print varies so much on different policies that it's really an impossible question to answer in a blanket statement. I have 2 examples.

I cut my hand severely a couple of years ago. A friend drove me to the ER where I got 24 stitches in my palm. I got a bill for about $500. I paid the $50 copay and insurance paid the rest. I also needed to have an outpatient surgery a few weeks later to repair nerve damage in the hand from the accident. I had to pay the first $400 of the surgery and insurance paid the rest, which was roughly $10,000. Then for the following 2 years I had to do follow up visits with a specialist and pay a $20 copay per visit, insurance paid the rest.

In that situation my insurance plan really took care of me.

More recently (and with a different plan from a new employer) my 10-year-old ended up in the ER with a fever of 103. He had a spider bite on his leg that he kept scratching and it ended up with a serious staph infection that got into his blood. Long story short he was admitted and in the hospital for 3 days. I thought insurance would have covered all but the copays, but we got a bill for $1,900 that insurance is refusing to pay. Now we fight about it, and more than likely I'll end up being responsible for the balance.

[octane]

Yama - not to be the pointer-outer of bad things, but how long have you been without coverage? Most plans will deny you entry for a pre-existing condition if you're uncovered for 60 days...so if at all possible it's important to stay covered one way or another.

Even for an emergency? If it's an emergency, my plan will pay as if I were at a preferred hospital...

So I guess it really depends on the fine print and plan -- some plans do cover you in case of an emergency when you have really no choice which hospital you go to.  Others cover some portion of it as Gisser mentioned (60% of it).  That's really not too bad, unless the emergency is an emergency by-pass procedure.. even 40% would be several thousands of dollars I'd guess.

i was "discontinued"from a medicaid program

?  How can you be kicked out of a program, unless you lied on the initial application, or perhaps abused it in some way?  Or perhaps you need to re-apply in some way every year or few years, and if the criteria changes, the option to not renew exists?  I thought medicare and medicaid would cover you when all else fails.  The coverage may not be as good as some "premium" health insurance providers, but it was at least available.

. nope our illustrious governor, decided to trim the state budget, which included cutting me, and 400k others out of the tenncare program (state version of medicaid.) plus i find out i cant appeal, cause, i either have to be on dis-ability, female, be younger than 19, be crazy (documented), hell i dont qualify for state medicaid :x . hmmm what to do, hell if i could go to canada, id be there lol :dunno:. basically for me to get back on it, i need to qualify for fed. medicaid, or have a disability :dunno:

[indestructibleman]

i think someone already pointed out that the problem is not just how the insurance works, but how expensive medical treatment is.

i wouldn't be surprised to find that the rise in medical costs coincided roughly with the privatization of hospitals.  whereas hospitals used to be a public service, many are now a for-profit business.

the problem with hospitals being for-profit is that not too many people have the luxury of comparison shopping when they're bleeding to death internally.

so, with an effective local monopoly, the hospitals increase their profits by charging more for less.

Senator Bill Frist's family made millions off of the privatization of hospitals.


cheers,
will

[sys49152]

octane, thanks for the examples.  So again, it really depends on your insurance provider's policies.  And even so, it's difficult to fully understand what is part of the standard coverage until you find yourself in a situation where you require that coverage.  Not unlike dealing with auto insurance.

..rise in medical costs coincided roughly with the privatization of hospitals.

This is news to me.  In fact, I thought that all hospitals/clinics/whatever were always privatized.  

Most would say it's inevitable that we will also move to a blended public/private system here in Canada.  I think some type of fee for service will likely be introduced in the near future.  For example, they'd like to decrease the number of people that show up at hospital emergency centers because they've got a runny nose.  Those kinds of visits usually cost around $250, paid entirely by the provincial government to local government health agencies which will eventually pay local health care workers.  Which means as tax payers, we contribute to paying for those visits.  A significant portion of it is subsidized by our government, but what remains accounts for a relatively large part of our annual taxes.  

But, if the same visit to emerg cost you $100, you might not go if you've just got a cold.  You might wait to see your family physician Monday morning.  At the same time, I'd hate to think that a low income family with a child running a high fever decides to wait three days because "maybe it's nothing, we could save the 100 bucks".  

The other option, and one that's currently being tried, is to ask people to phone  into a health call center prior to heading to the hospital.  The 24/7 on-call nursing staff offer advice and will encourage or discourage the caller from heading to emerg, depending on the symptoms/history.  They also have on-call doctors to assist if they can't answer the questions.

[indestructibleman]

sorry, i shouldn't have used the term privatization.

my concern is more the increase of for-profit hospitals.

did a bit of research and discovered i may have been off the mark.

from wikipedia:

In the United States the traditional hospital is a non-profit hospital, usually sponsored by a religious denomination. One of the earliest of these "almshouses" in what would become the United States was started by William Penn in Philadelphia in 1713. These hospitals are tax-exempt due to their charitable purpose, but provide only a minimum of charitable medical care. They are supplemented by large public hospitals in major cities and research hospitals often affiliated with a medical school. In the late twentieth century chains of for-profit hospitals have arisen.

from another article i found:

The American Hospital Association lists over 6,000 hospitals in the US. The majority of these are not-for-profit hospitals, and treat about 75% of all hospitalized patients. For-profit hospitals and governmental hospitals each account for the remaining the hospitals and patients treated.

so apparently the significant majority is still not-for-profit.

[octane]

Actually IM, the main reason for healthcare costs skyrocketing in the U.S. is the extreme cost malpractice insurance faced by healthcare providers. My father-in-law is a doctor and I've had many long discussions with he and some of his colleagues about malpractice premiums. A few of his friends have taken early retirement or changed specialties because they simply couldn't afford to practice despite the fact that they were experienced physicians with spotless histories that became doctors because they wanted to help people.

It's been so easy to file frivolous lawsuits in the U.S. for so long, insurance companies have been hit hard. Who pays for that? Ultimately every American in need of healthcare, but first hit are the doctors who need malpractice insurance. Now I'm not saying that there are not many legitimate lawsuits filed by people who are deserving of million dollar settlements, but I do think there are far too many huge amounts of money awarded in court - or more often settled out of court because it's cheaper for the insurance company than paying a trial attorney - that aren't fully justified.

I also think, and this is my personal opinion, that people sometimes expect too much from doctors. Doctors are human and will sometimes make mistakes. And not all injuries or ailments can be repaired. I believe everyone is entitled to good quality healthcare, but when you go to the hospital or your doctor for help and they give you the very best care they are able to and things still don't work out for you, I don't think that gives you a right to sue them. Too many attorneys do think that is grounds to sue...and get away with it.

Negligence should not be tolerated under any circumstance, but I don't think physicians are looked out for enough. Any of you recently had or planning to have a child? It's getting tougher to find a OB-GYN to deliver, especially if you want to go with a midwife or natural delivery. Scheduled c-sections are becoming normal procedure - there is nothing normal about that. Why? Because it creates a controlled environment for the doctor doing the delivery and presents less unknown variables for potential problems - and the malpractice suit that would be sure to follow.