People living in USA. Please come and talk to me about health care.

(44 Posts)
ilovemydogandMrObama Fri 18-Jun-10 13:44:48

It's been about 10 years since I lived in the USA, and my mom is a doctor, so didn't really have to worry pay much in insurance.

How does it work with children? Prescriptions? Deductible and co payment?

DS gets hypoallergenic formula on prescription and DD has asthma, so both are pre existing conditions....

How much are GP appointments? Am wondering about an HMO.

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TheButterflyEffect Fri 18-Jun-10 14:56:50

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TheButterflyEffect Fri 18-Jun-10 22:57:43

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marenmj Fri 18-Jun-10 23:20:14

ok... short answer is: it depends (on where you live and which company you are with) and should be outlined in your insurance plan.

long answer is: it REALLY depends.

IF you are living/staying mostly local and have a good hospital/network nearby and none of you have a rare or specialised condition, HMO's are FAB and the way to go. Usually there is an 800 (toll-free) number on the back of your insurance card and they can direct you to nearby in-network providers. HMO's also maintain good websites with lists of in-network GPs etc. I used to call the toll-free number for my HMO and they would schedule appointments with the Dr's office for me grin

When I had HMO coverage the co-pay for seeing the GP, regardless of service, was $20, as is the co-pay for prescriptions. Ensure your GP knows and writes on the script that generics are acceptable (just in case).

IME, functionally an HMO operates a lot like the NHS. Most services are covered IF you get them from a network provider (and other services aren't). Other than your co-pay, all the money/billing happens behind the scenes and you don't have to bother with it.

AFAIK HMO's usually cover pre-existing conditions, with some exceptions (i.e. DH used to get limited coverage under one because he had a kidney removed as a child). Our current HMO actually advertises that they do not disqualify coverage or limit coverage based on pre-existing conditions as a selling point ;)

In 2014 when the new healthcare rules go into effect insurers will not be allowed to disqualify/charge more based on pre-existing conditions or gender.

HMO downsides are:
+ if you or a family member have a special condition that you are already seeing a specialist for, treatment with that Dr might not be covered until an in-network GP refers you to them. Also, if you already have a GP and are set on keeping them, they may not be in the HMO's network so wouldn't be covered.

+ if your closest ER is at a hospital that is not in-network your likelihood of being rushed to the ER and incurring out-of-network costs goes up. Again, a lot of companies advertise that they automatically cover this sort of thing (mine also advertises that they cover expenses while travelling as well)

DISCLAIMER: I have never had to claim large expenses when on an HMO, just GP visits and prescriptions, so I really haven't had the opportunity to have a bad experience with one. YMMV.


I had a v v expensive PPO coverage plan a few years back and would never recommend it. DH and I paid $560/month for coverage for just the two of us, and only claimed two physical exams (one for each of us), which were supposed to be fully covered once per year under our plan. The insurance company paid DH's and refused to pay mine because mine had included a gyno exam (wtf??). It was a $300 office visit. We cancelled the plan and set up a medical savings account instead.

tadjennyp Sat 19-Jun-10 05:10:14

I think marenmj's answer is excellent. I have coverage through my husband's job and I don't trust the company as far as I could throw them. You have to be so careful about who is in network as they will not pay if they're not.

I had a mole removed last year and originally went to a dermatologist I thought was in network. Turns out he wasn't and I had to pay for that office visit. The next lot I went to were in network and they removed it and discovered the mole was changing. However the lab the mole was sent to was not in network and I had to pay that charge too! Apparently when someone is performing surgery on you, you are meant to ask which providers are doing which bit! grin

marenmj Sat 19-Jun-10 09:04:31

Ugh, different providers for one procedure... YES.

My HMO ran the nearby hospital and a whole campus of practices around it, so IF you were at that hospital or in one of the offices around it, you could be sure it was ok, but otherwise, no guarantees (i.e. I broke my finger, saw my GP for it, who sent me to the hospital next door for xrays, back for asessment with him where he nearly slapped me for carrying on with a broken finger for two months grin - all covered as it had been done on their campas).

I was lucky as I lived a few blocks away from their hospital, so it was the most convenient medical campus anyway, but I have heard horror stories about HMO networks.

We're on a very good, local HMO now, but have not had reason to use it yet. We will though, sooner or later.

So if you're in a similar situation where the HMO maintains hospitals (where all the docs will be "in-network") and a bunch of local practices it is great, but if you aren't then dealing with an HMO network will be nothing but a PITA and you're better off with whichever provider will get you the broadest coverage.

ilovemydogandMrObama Sat 19-Jun-10 22:36:29

Thank you so much for responses smile

So, Kaiser and other HMOs seem fairly similar to the NHS? Needing to be referred to a specialist, and for further tests, if needed?

Roughly how much are prescriptions, and what is the percentage for a co payment? Are there any discounts for children's medicines?

My biggest fear about the US system is having to argue with insurance companies as to whether a treatment/visit was necessary, so an HMO sort of takes that out of the equation....

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marenmj Sun 20-Jun-10 01:30:16


Yes, a robust HMO functions a lot like the NHS. You go see your [in-network] GP for a nominal co-pay. If you need specialty treatment they refer you to [in-network] specialists for for further tests. Similarly to the NHS, provided the GP and specialists say it was necessary, the treatment should be covered. (barring things like a specific exclusion in your plan, which you should be able to read before you sign anything)

With HMO's the big complaints come up with out-of-network providers. For instance, if you are hit by a car and rushed to the ER (unconcious so you can't object) and the ambulance and hospital are out of network, the HMO may refuse to cover those charges. However, most HMO's recognize what an insane PR move that is and will advertise that they cover all emergency care.

As with the NHS, you simply won't get a breast augmentation covered by an HMO (or PPO afaik). My GP used to send in every mole he removed for biopsy as that would "prove" to the HMO that it was necessary to remove it rather than cosmetic (even if it was probably mostly a cosmetic/convenience request).

My co-pay for prescriptions was $20 and as of last December it hadn't changed. I don't think the rate is different for a child's prescription, but that would be laid out in the plan. I know people who don't bother claiming simple prescriptions because the cost of the medicine is less than the co-pay (doesn't make sense to pay a $20 co-pay for a $10 medicine iyswim).

If you have an HMO you likely won't be arguing directly with the insurance company about necessary treatment or visits. Like the NHS, it more or less works for a basic level of care and the things you hear about on the news are usually something specialty - not that you won't have any unusual circumstances, but that you need to be aware if/when your choice of company could be a problem. DH is more likely to need an organ transplant if his one remaining kidney gives out, so we won't sign up with companies who exclude organ transplants from coverage etc. I have a Danger Girl toddler, so I make sure that we live near an in-network hospital and the local ambulance company is covered. Etc etc etc.

If you're worried about it you should definitely check the Kaiser website (Kaiser Permanente is meant to be a fairly good one iirc) and see what levels of coverage they offer. If you or your kids have a chronic condition you will want to be careful of lifetime caps on treatment.

Also check the new healthcare legislation as that will change things quite a bit in four years.

Finally, a quick note, Kaiser Permanente is a REALLY big ins company, covering much of the western US, so the will have a large number of complaints online. Sometimes it's really useful to read the horror stories as they can give you an idea of how the system works and what might be expected of you.

mathanxiety Sun 20-Jun-10 03:52:59

My experience is of a major network, Blue X/ Blue Shield (but at the moment they are all done state by state) with a PPO option, that we had through exH's work. You can find out what providers are in-network by going online or just phoning the company, and you should also phone the doctor or other provider too. I had no problems fighting for coverage of items like DS's mole removal or DDs' asthma prescription -- that's up to the provider to do with the company, and most of my family's treatment was very standard and unexceptional. The PPO providers charge a lower rate to subscribers, but the proportion that you pay (not a co-pay at the time of visit, but a proportion of the bill that you are responsible for) was 20% until the out-of-pocket deductible was met -- the deductible can be $500 or $1000 or more per person, or per family per annum. There was no co-pay, which is a fixed charge of usually $10 to $20 at the time of the visit, iirc.

I have also had experience of pay it yourself/ individual health coverage before exH got over his self-employment jag, and it sucked, pardon my French. We basically had only emergency coverage, for admission to a hospital through an emergency room and any out-patient services rendered through an emergency room, like x-rays or stitches, etc. There was no maternity coverage, and no well-child visit coverage -- that means we paid top dollar for (mandatory for school) vaccinations. Luckily, my pediatrician took pity on us and had us fill out an 'insufficient insurance coverage' form that gave us a discount, but I'm not sure if this would apply in every state, or even every pediatrician; mine was a practice attached to a major teaching hospital. No medicine coverage -- paid through the nose.

No such thing as prescription baby formula, hypoallergenic or not. You go to Walmart and buy it and you'll never see that money again. A prescription for anti-biotics for an ear infection, yes that would be covered except by insurance like I had for emergency treatment only.

US healthcare stinks.

sarah293 Sun 20-Jun-10 06:15:02

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ilovemydogandMrObama Sun 20-Jun-10 17:08:31

Have read the horror stories about Kaiser shock shock shock. Wow. Really scary stories. Suppose that's what scares me the most; not the final cost of a medical procedure or treatment, but the worry that one will get sick and not be able to get the proper treatment based on inability to pay rather than clinical need

riven I tend to have tantrums on a regular basis as far as living in this city, and go through a 'grass is greener' phase, but am seriously thinking about it. We are going to Seattle for Thanksgiving, and am doing a bit of research. considerate of DD to break her arm in Canada though...

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sarah293 Sun 20-Jun-10 17:20:31

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Earlybird Sun 20-Jun-10 17:20:58

Bit of general information - google 'health savings accounts'. I know quite a few people who are handling their health insurance in this way.

Most (all?) states have local government funded insurance programs for people who are considered 'uninsurable' - those with many pre-existing conditions, can't afford, etc.

Once you know which state you'll live in, you can look into how to sign up. When giving birth to dd, I had my hospital stay/c-section costs covered by one of those programs, as i was considered 'uninsurable' by traditional companies due to my pregnancy being considered a 'pre-existing condition'. hmm.

It was a bit of a faff signing up, but gave me tremendous peace of mind to know i was covered in case something went catastrophically wrong.

JJ Sun 20-Jun-10 17:22:29

ilove- not sure how old your children are (am assuming your son is quite young) but some states have excellent Medicaid plans for children. Eligibility varies quite a bit from state to state but you should definitely look into it. My sister used it for her two in 3 different states and had excellent care.

My family used Cigna and they were excellent - however service with any provider will vary with the plan. It sometimes seems the more you can afford, the less you have to pay.

I think that some new Medicaid things roll out next year, too, but I don't know the details if there are any.

The thing to remember is that everything, I think, varies from state to state.

Earlybird Sun 20-Jun-10 17:24:00

JJ and i are talking about the same program - Medicaid. It is called different things in different states.

jabberwocky Sun 20-Jun-10 17:29:35

I really don't like HMO type plans. It seems those are the ones where the arguing over a treatment might occur, although it's really only things like experimental cancer treatment, etc. that you might have a problem imo. I have an individual plan for me and the two boys. It is just under $300 a month. I went for a straight deductable plan as we hardly ever go to the dr. anyway. So, we pay a discounted charge for visits up to a max of $1500 per year and then the insurance covers 80% of all costs after that. I can't remember our total max coverage but it is quite high. I have never had a problem with any testing I wanted (requested extensive bloodwork on ds2 last year for recurrent ideopathic fever) and we haven't had to worry about which doctor we go to so far.


Earlybird Sun 20-Jun-10 17:35:40

<waves to jabberwocky>

For our healthcare, I have now done a version of what jabberwocky describes - have quite a high annual deductible (in exchange for lower annual/monthly fee), as we're relatively healthy 'round here. Our health care coverage will only kick in for catastrophic problems. We also have an 80/20 split, and the same percentage co-pay for annual exams.

One thing to keep in mind - many companies now are issuing policies with a maximum lifetime amount. I think ours is $5M. ATM, that sounds an enormous amount but imagine real/ongoing health issues could drain that amount eventually. Don't know what happens to those who exceed their allowable amount.

JJ Sun 20-Jun-10 17:41:32

Yes, cross-posted with Earlybird.

Another thing that occured to me but you're not thinking about not insuring yourself, are you? I wouldn't do that - I mean, you definitely need insurance for you, too.

We're American (live in UK) and recently signed up to a worldwide health insurance plan because we spend 6 weeks a year in the US. Before that I always made sure to get specialist insurance to cover costs there (my son has pre-existing conditions). I wouldn't even visit and never have in the 10 years we've been away without sorting insurance.

Earlybird Sun 20-Jun-10 17:47:33

JJ - can you share the name of the company?

I never could get that sorted, so ended up in the ludicrously expensive situation of paying for private health insurance in the UK and the USA. Crazy.

ilovemydogandMrObama Sun 20-Jun-10 17:49:51

Wow. A lot of information there. That's me busy this evening! Thanks so much grin.

I like the idea of HMOs, but maybe in practice they aren't great?

Am rather traumatized by the whole issue of health insurance as my dad was in a car crash (uninsured) taken to nearest hospital, spent 13 days in intensive care. every day the doctor said he would be helicoptered to county hospital, when they thought he could be moved. Unbelievable. There he was on life support, unconscious, and the doctor was talking to me about how I was going to pay for it. Oh, and I was 16 years old.

grin at 'Don't know what happens to those who exceed their allowable amount...' It makes you wonder though...

Riven, you have my mobile, and were going to text me when you found your diary?

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Earlybird Sun 20-Jun-10 17:54:03

FWIW - my Bil went to the hospital accounts office the day his Mum was discharged. He calmly told the clerk that they'd only pay 60% of the bill (the part not covered by insurance), and the hospital agreed without argument!

It seems many hospitals almost expect to barter on the bill - at least according to my BIL.

marenmj Sun 20-Jun-10 18:47:40

many hospitals also bill one amount for insurance and a different amount for cash.

I don't think it's so much that they expect to barter, but that the price structure is set at something inflated for insurance, but they agree to a smaller portion for people who pay themselves since the know that the alternative is getting nawt.

Usually they will also agree to a monthly payment plan arrangement, iirc.

mloo Sun 20-Jun-10 19:16:39

I was born in a Kaiser hospital (1967), my mom died in one, and my other folks are still with them. Can't complain. They've been good for us, but our health package comes thru a local govt. (County + State) employer, which may make a difference.

mathanxiety Sun 20-Jun-10 19:32:54

The costs can be huge, though. When DD2 was born the hospital sent me an itemised bill for something between $24,000 and $25,000, for a delivery that took 40 minutes from when we arrived at the hospital door, with no pain relief, no anesthesia, and just a resident on duty, and I left 24 hours later. DD didn't even spend time in the newborn nursery.

The OB/GYN bill for the prenatal care came later, but that was also covered 80/20, and we also paid in installments. The hospital bill was just a courtesy bill, as we had insurance at the time, and the insurance paid 80% in the end. We paid the rest in increments.

WRT Medicaid in its various forms -- most states are either bankrupt or almost bankrupt. Many are way behind in payments to doctors and hospitals, and everyone else who does business with them. Doctors do not have to accept Medicaid patients -- in some areas they are few and far between, and many of course stop seeing Medicaid patients when they don't get paid, and only see self-pay or insured patients. It can be difficult to find someone willing to accept your Medicaid coverage.

And unless you are a citizen, have a green card, or are an undocumented pregnant woman, you will not be eligible. The type of coverage that you can get if you're pregnant is not the same as regular Medicaid. Regular Medicaid coverage has strict income limits. Pregnancy coverage has income limits afaik, but is available even if you have insurance but that insurance doesn't cover maternity care. When your baby is delivered, the coverage stops after a certain period and you have to apply for regular Medicaid.

sarah293 Sun 20-Jun-10 19:50:44

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