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Old 3rd July 2014, 02:56 PM
mamy1024 mamy1024 is offline
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Join Date: Jun 2014
Location: Macon, Ga.
Posts: 2
Default Health Insurance question

Does anyone here know much about how health insurance works? Specifically, if my hospital stay begins at the end of December and carriers over into January, will I have to pay my deductible for both 2014 and 2015?

My deductible is $2500, of which I have already paid nearly $1000, so if I am understanding this correctly I will pay $1500 of medical expenses involved in the spinal fusion- as long as those expenses incur before the start of 2015. Eh?

I have a choice of when to schedule this surgery, I can do it anytime in December, but I have a 7 year old and I don't want to ruin his Christmas or miss out on it. But if it means spending an additional $2500 then that's something to consider.
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Old 8th July 2014, 04:55 AM
Mari42 Mari42 is offline
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Join Date: Mar 2013
Location: Oklahoma, USA
Posts: 129
Default Re: Health Insurance question

Hey there! I'm one of the few Americans on here, as most of the other people are from the UK and deal with the NHS system there.

There's a few general types of insurance, but for specific questions about your policy, I suggest that you call the number on the back of your card. With a little effort, you should be able to talk to someone who will explain exactly what is covered. It's what I did!

1)There's high deductible insurance, which means you pay out of pocket for any services you need until the deductible is met. After the deductible is met there is often a co-pay period, which means that the cost of the services is split between you and the insurance company. A common co-pay is 80/20, where the insurance pays 80% and you pay 20%. Often there is a total out of pocket cap for the year, which includes the deductible and any copayments. After the out of pocket cap is met, the insurance covers the services at 100%.

2)There's the copay route, where the cost is split between the insurance company and the insured. Given that you mentioned a deductible, I will assume for the moment that you have high deductible insurance.

Most deductibles and out of pocket caps run from 1 January through 31 December, and start over 1 January the next year. For that reason, I would be cautious of scheduling a surgery in December. You want to be out of the hospital well before December 31 to avoid paying the deductible and out of pocket this year and next year.

***Assume that you will pay up to any out of pocket limit your plan may have. Scoliosis surgery costs around $250,000-$300,000 USD.***

Here's an example from my own experience. My plan has a $1,500 deductible, and a $4,000 out of pocket max for the calendar year. I had to pay all doctor appointments, etc. until I had paid $1,500. After that point, my plan had a copay of 80/20. Each doctor appointment or service after I met my deductible was 80% paid by my insurance, and 20% paid by me. This period lasted until the $1,500 deductible and the copayments equaled $4,000. (And yes, my surgery cost over $300,000.)

I was in the hospital for 10 days the first time. If I had spread a hospital stay over two calendar years (December to January) this is what it would look like. $1,500 deductible and $2,500 in copayments = $4,000 for this year, and $1,500 deductible and $2,500 in copayments = $4,000 for next year. The total cost for a 10 day hospital stay from 30 December through 8 January would be $8,000, vs $4,000 if the entire stay had been in one calendar year like 1 December through 10 December.

You know your situation better than anyone else, but I would suggest having surgery before December if you have a similar plan to mine. Unexpected things happen, so I would want to be sure there is little chance of going into the next year.

If something doesn't work out to make surgery a good idea this year, I would wait until next year to schedule. There is little chance of the scoliosis getting significantly worse in a few months. Yes, you mentioned that you have already paid $1,000 of your deductible this year, but if you look at the calculations above, you'd only pay $5,000 by waiting until next year, vs $8,000 if you spread a hospital stay over late December and early January.

Good luck to you on your surgery! I know it's a big decision! Again, contact the number on your insurance card to get the details of your specific plan! I just used my plan to illustrate the issue, because it is similar to many other high deductible plans.
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Mari
29 years old, diagnosed with AIS at age 14. Now have a 58* thoracic curve, a 37* lumbar curve, and a 20* high thoracic compensatory curve. Due for surgery at the Baylor Scoliosis Center in September 2013.
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