Question about medical insurance.

Status
Not open for further replies.
Joined
Aug 5, 2002
Messages
23,086
Location
Silicon Valley
Wife is evaluating her medical insurance change, and the new plan (Blue Shield California Gold Full PPO) has a 40% out of network coverage for non registered provider, with a allowable amount limitation.

Our acupuncture provider got burnt last year after I switch job, and almost didn't get paid, because the allowable amount and number of visit is so low that basically everything is going to be expired after deductible is paid for, and he is too nice to charge people before deductible. Prior to this insurance I worked at a place that has very nice insurance that paid for everything almost.

So, does anyone know how can we find out what the allowable amount per visit is (it is not anywhere I can find out without filing a claim)? Despite being PPO with 40% deductible out of network, this allowable amount will still limit how they will be paid and whether we will be covered or not.
 
from what Ive found is if you pay more(premiums) for a better plan you will get more paid coverage and less out of pocket costs, its a case of pay me now or pay me later. if your getting your health insurance through your job theres not much you can do about what type of plan coverage you'll get cause most places don't like to pay high premiums for their employees Cadillac health care plans, when the premium costs go up the employers shift the costs to the employees to pay out of pocket and lower the plans coverage on certain procedures/prescription drugs
 
does anyone know how can we find out what the allowable amount per visit is (it is not anywhere I can find out without filing a claim)?
I have never been successful. If you call the insurance company, they tell you that they can't tell you without knowing the provider and CPT code. If you manage to get it from the provider, then they come up with an excuse, they can't tell you until they receive the bill.
I have been burned a lot by a medical insurance company's sleazy tricks. So I make sure that the plan I have has solid hospital coverage. For the rest, I usually pay out of pocket.
 
Wife is evaluating her medical insurance change, and the new plan (Blue Shield California Gold Full PPO) has a 40% out of network coverage for non registered provider, with a allowable amount limitation.

Our acupuncture provider got burnt last year after I switch job, and almost didn't get paid, because the allowable amount and number of visit is so low that basically everything is going to be expired after deductible is paid for, and he is too nice to charge people before deductible. Prior to this insurance I worked at a place that has very nice insurance that paid for everything almost.

So, does anyone know how can we find out what the allowable amount per visit is (it is not anywhere I can find out without filing a claim)? Despite being PPO with 40% deductible out of network, this allowable amount will still limit how they will be paid and whether we will be covered or not.
You will need to call Blue Cross and tell them you want a copy of the EOC (Evidence of Coverage) and they will send it out to you. The EOC is the full contract and have what you need in it.
I would think you may already have it but maybe not. I have been reading through almost a dozen of them in my home state online as I am thinking of making a change in the next 6 months.

You do not state exactly what plan you have but this is an example of the EOC for your general plan. The "Summary" is the first 19 pages and starting on page 20 is the EOC, its over 60 pages long but the answer to your question ishould be in there or else you will just need to call them. I would go through it for you but there is a lot... and beware you need your exact plan, for example this is the Full Gold 0/20 plan but there are others too.

Here is an example of the EOC, again, starts on Page 20 = EOC, CA Full Gold Plan


Anyway, for your plan, Blue Cross says to contact them and they will send it out. Your answers will be in the EOC as stated in the first paragraph of the link I provided.
BC - CA - Gold - Click here.

In the notes section at the bottom of the above link it instructs you to call them for a copy of the EOC;
Screen Shot 2021-04-01 at 7.17.22 AM.png


___

I think you can forget everything I said above, if you want to know what they will pay, you will need to call their customer service # .
AS I think others have said, will most likely also need procedure number but cant hurt to call them. I think there is a number on page 68.
 
Last edited:
Pay out of pocket without using insurance and do a manual claim form once. They will reimburse you the answer you are looking for. At the end of the day, you are comparing a group insurance policy to an ACA plan. There is nothing affordable about the Affordable Care Act, unless you are destitute. Even those folks that have a Cost Share Reduction and a very large Subsidy cant afford a reduced deductible of a few hundred dollars and minimal copayments of, lets say 5 to 10 dollars. Individual or family health insurance for people under 65 (outside a group policy) is a complete joke. I could go on but its too early for me to get on this soap box.
 
Zero reason he/she doesn't get paid in full. Whatever insurance doesn't cover, you cover.
Which is what I want to avoid. He/she used to waive our out of pocket part despite being PPO (because he/she still comes out ahead), but this changed recently when we switched job insurance, so he still "took care of us" because we have been going there for years and he knew our situation (pre-existing condition). The problem with acupuncture / chiropractic is that they are not exactly a science but more of a skill, finding where you need adjustment / how much is really not the same for everyone. The one we went to work fine for my wife but not for me. The one works fine for me doesn't work fine for my wife.

from what Ive found is if you pay more(premiums) for a better plan you will get more paid coverage and less out of pocket costs, its a case of pay me now or pay me later. if your getting your health insurance through your job theres not much you can do about what type of plan coverage you'll get cause most places don't like to pay high premiums for their employees Cadillac health care plans, when the premium costs go up the employers shift the costs to the employees to pay out of pocket and lower the plans coverage on certain procedures/prescription drugs
We have choices between 2 jobs and we are comparing the top PPO between them. It used to be PPO will let you cover everything as long as you are in it for a percentage of the payment, but they now cap the allowable amount to a point that basically, from my last insurance, with maximum number of visit, you are responsible for 100% of it if you go out of network.
 
You will need to call Blue Cross and tell them you want a copy of the EOC (Evidence of Coverage) and they will send it out to you. The EOC is the full contract and have what you need in it.
I would think you may already have it but maybe not. I have been reading through almost a dozen of them in my home state online as I am thinking of making a change in the next 6 months.

You do not state exactly what plan you have but this is an example of the EOC for your general plan. The "Summary" is the first 19 pages and starting on page 20 is the EOC, its over 60 pages long but the answer to your question ishould be in there or else you will just need to call them. I would go through it for you but there is a lot... and beware you need your exact plan, for example this is the Full Gold 0/20 plan but there are others too.

Here is an example of the EOC, again, starts on Page 20 = EOC, CA Full Gold Plan


Anyway, for your plan, Blue Cross says to contact them and they will send it out. Your answers will be in the EOC as stated in the first paragraph of the link I provided.
BC - CA - Gold - Click here.

In the notes section at the bottom of the above link it instructs you to call them for a copy of the EOC;
View attachment 52148

___

I think you can forget everything I said above, if you want to know what they will pay, you will need to call their customer service # .
AS I think others have said, will most likely also need procedure number but cant hurt to call them. I think there is a number on page 68.
Thanks. Will they tell me if I am considering the job but not yet enrolled?
 
Pay out of pocket without using insurance and do a manual claim form once. They will reimburse you the answer you are looking for. At the end of the day, you are comparing a group insurance policy to an ACA plan. There is nothing affordable about the Affordable Care Act, unless you are destitute. Even those folks that have a Cost Share Reduction and a very large Subsidy cant afford a reduced deductible of a few hundred dollars and minimal copayments of, lets say 5 to 10 dollars. Individual or family health insurance for people under 65 (outside a group policy) is a complete joke. I could go on but its too early for me to get on this soap box.
100% true statement, im going thru GetCoveredNJ health insurance State insurance portal to buy mine, I run out of my 18 month COBRA insurance at $744 month with dental included for single/individual, and just called my ex employer(Union organization) for an extended few months of it and no go (of course) so my option is Medicaid or the NJ get covered Portal, it will cost me $914.54 per month of Blue cross/blue shield of equal as my previous insurance, this is with State subsidies and discounts, so its $170.54 per month extra and $2046.48 extra annually for equal coverage I once had. if I had chosen another less expensive plan I would have to pay more out of pocket expenses for my Medical needs or just not got to a doctor, most of the low cost ACA plans you cant afford to go to a doctor cause youll be paying $6000 dollar deductables before they will even pay a measely Co-insurance, your paying every month just to say you have insurance not to actually go to a medical/doctor facility.
 
Last edited:
Which is what I want to avoid. He/she used to waive our out of pocket part despite being PPO (because he/she still comes out ahead), but this changed recently when we switched job insurance, so he still "took care of us" because we have been going there for years and he knew our situation (pre-existing condition). The problem with acupuncture / chiropractic is that they are not exactly a science but more of a skill, finding where you need adjustment / how much is really not the same for everyone. The one we went to work fine for my wife but not for me. The one works fine for me doesn't work fine for my wife.


We have choices between 2 jobs and we are comparing the top PPO between them. It used to be PPO will let you cover everything as long as you are in it for a percentage of the payment, but they now cap the allowable amount to a point that basically, from my last insurance, with maximum number of visit, you are responsible for 100% of it if you go out of network.
this is why people breath a sigh of relief when they can finally be old enough to get MEDICARE insurance, the Health insurance game is a jungle to deal with even if you have insurance thru your job you still have to fight and read all the fine lines of whats covered and the out of pocket costs, most all the people ive worked with over the years never gave one thought about their insurance coverage till tragedy hits with an issue then they are shocked at their out of pocket costs, mostly because they never negotiated or cared about it. Forewarned is Forearmed
 
Which is what I want to avoid. He/she used to waive our out of pocket part despite being PPO
Trust me, I could rant about medical insurance in the US.... but I won't. :LOL: In your case, this is just a downside of going out-of-network. My wife and I continued seeing our long-time family doctor and paid out of pocket for a year due to insurance bickering (the hospital network he was in was in a dispute with the insurance we had at the time). I did the same with my eye doctor - paid out of pocket because I didn't want to switch. In both cases, they had arrangements for "cash" customers but they were pretty discrete about it.

It's ultimately his/her call when it comes to waiving add'l costs. Talk to them and explain what's going on, that you want to continue using them, costs, etc. This is in addition to what you're trying to find out from your insurance.
 
I’d ask the acupuncture provider what they’d charge for a cash visit. The amount they typically get from any copay and what the insurance company pays is pretty low so they may work something out with you to avoid the claims hassle and it could end up being similar out of pocket for you.

I do this with my dentist and skip dental insurance. She makes more, I pay less when you figure the premiums and copays.
 
I’d ask the acupuncture provider what they’d charge for a cash visit. The amount they typically get from any copay and what the insurance company pays is pretty low so they may work something out with you to avoid the claims hassle and it could end up being similar out of pocket for you.

I do this with my dentist and skip dental insurance. She makes more, I pay less when you figure the premiums and copays.
I was going to suggest the same. Acupuncture is probably not common, so YMMV. Might be less costly for both parties to pay cash as you go. No claims processing or time spent on the tedious task.

But as far as finding out what a potential employer's coverage pays, maybe the HR person can provide the benefits details. I would think there are amounts listed for things such as acupuncture and chiropractic services.
 
I honestly don't know. I would think they would being you are considering their insurance.
I suspect they won't tell him, in fact, they can't tell him. Employers dictate the fine details of employee-provided healthcare plans so the answer very well could be, "it depends".
 
I do this with my dentist and skip dental insurance. She makes more, I pay less when you figure the premiums and copays.
At the dentist this morning, I overheard the dentist talking to a patient about insurance. Sounded like the patient was a single guy (so no "family" coverage) and he was saying how high his dental premiums were for his insurance. The dentist suggested he drop the coverage and sign up for the "membership" plan he offers - $25/month, includes (2) cleanings per year, etc, etc. Any "major" work is 20% off the insurance rate. Which, I don't know, 'cause every insurance could pay slightly different rates... Maybe he offers it at the lowest. He actually said his incentive was for his older patients after they retired and had poor dental insurance or none and he didn't want the 10, 20, 30 years of dental care he provided some to go to waste. I know, I know, it sounds fishy, but honestly, he doesn't have to offer anything either.
 
At the dentist this morning, I overheard the dentist talking to a patient about insurance. Sounded like the patient was a single guy (so no "family" coverage) and he was saying how high his dental premiums were for his insurance. The dentist suggested he drop the coverage and sign up for the "membership" plan he offers - $25/month, includes (2) cleanings per year, etc, etc. Any "major" work is 20% off the insurance rate. Which, I don't know, 'cause every insurance could pay slightly different rates... Maybe he offers it at the lowest. He actually said his incentive was for his older patients after they retired and had poor dental insurance or none and he didn't want the 10, 20, 30 years of dental care he provided some to go to waste. I know, I know, it sounds fishy, but honestly, he doesn't have to offer anything either.


My dentist charges $100 for a cleaning, X-rays, fluoride treatment. She will do other procedures at a discounted rate. Beautiful office, new equipment, great staff. I have no complaints at all. My share of my old employer dental premium was about $200/year for my wife and I. With insurance the fluoride wasn’t covered by insurance and with the copay a cleaning was still like $40 each time. This way my dentist makes more money, and I pay about what I paid when I had employer subsidized dental insurance. If I had to pay for dental on my own now it would be even more expensive.
 
I suspect they won't tell him, in fact, they can't tell him. Employers dictate the fine details of employee-provided healthcare plans so the answer very well could be, "it depends".
Maybe, maybe not, all it takes is a phone call. He seems to have the specific name of the plan and company name.
 
Status
Not open for further replies.
Back
Top