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Living overseas

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Please tell me about US healthcare

21 replies

Moknicker · 25/07/2012 12:09

Just back from the hospital after a fraught night. DD has asthma and spent night on oxygen. Recovering now but realised how much I LOVE the NHS. We are moving to Washington DC in Oct and nervous about the US healthcare system. We will have insurance through DH's work but still...

What do I need to be braced for?

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NotMoreFootball · 25/07/2012 19:58

Are you moving permanently or on an expat assignment? If on assignment you should be covered 100% for all health expenses by your insurance company and employer. I just let the insurance company know when and where our appointments are and they call up the doctor / dentist in advance to arrange payment and I always carry our insurance policy number in case of emergencies. If the insurance company doesn't cover something then our employer picks up the bill.

NotMoreFootball · 25/07/2012 19:59

Are you moving permanently or on an expat assignment? If on assignment you should be covered 100% for all health expenses by your insurance company and employer. I just let the insurance company know when and where our appointments are and they call up the doctor / dentist in advance to arrange payment and I always carry our insurance policy number in case of emergencies. If the insurance company doesn't cover something then our employer picks up the bill.

joanofarchitrave · 25/07/2012 20:01

TBH I think if you have insurance, you will be blown away by the quality of the healthcare on offer.

CaliforniaLeaving · 26/07/2012 04:11

It seems every company has different coverage.
Some take a set amount from the pay check monthly for your share of the premiums others don't (we have no monthly payments)
The amount you pay out of pocket for doctor visits hospital stays, emergency room, labs and x-rays can vary too.
We once had insurance that we had a $5,000 a year out of pocket before the insurance paid 100% of bills.
Then there are co-pays (the amount you pay for each doctor visit) some are set amounts (we used to have one that was $20 per visit) now we pay 20% plus our deductible.
It's a mine field. I know many Americans that don't get how it all works. We have been her the best part of 25 years and still get stumped.
It's really quite a crap shoot, no one seems to be able to give you a figure for how much anything will cost (unless it's a plain old doctor visit) and you never know what the bills will look like till you get the Estimation of benefits (EOB) from the insurance company that shows what they were charged and what they paid and what your share of the bill is. I keep these and staple them to the bill that the billing dept from the hospital or doctor sends and keep it in my file (after paying the bill) I learned quickly to be good at keeping records of visits and bills and match it all up.
It's best to get the info from the HR dept of your Dh's new company just to be sure what is covered and what you will be paying.

fridakahlo · 26/07/2012 05:19

It has not been bad as such but not good either.
When we moved over we had reasonably good coverage, paid 300 to 400 dollars a month, had all the basic stuff covered minus a twenty or forty dollar co-pay depending on the type of doctor you wete seeing.
A three day hospital stay for our dd ended up costing us two thousand dollars, which was only twenty percent of the total cost.
Last year I ended up on an intensive three week out patient.pyschiatric program which was really really helpful and for some reason only cost us between four and eight hundred.dollars.
Would not want to do it this year as husbands company changed the policy they were willing to provide and our one thousand five hundred limit ran out so quickly.
If one of us is to end up hospitilised now, we would have to cover the first onethousand five hundred and then forty percent of the rest.
Fortunately employee satisfaction has dropped so badly they will be reviewing it come next year.
If you can afford the co-pays and the policies it's really good health care.
It's if your middle income, can't quite afford to pay into a policy that you get screwed or if you suffer from something long term/requiring intensive treatment.
Oh and be wary of declaring your daughters asthma.

Moknicker · 26/07/2012 09:56

All - thanks so much
Fridak - what are the implications of declaring DD's asthma or not? It has not yet been diagnosed as asthma as she is too young for the diagnoses but it looks likely that it is, so I do have the option of not reporting it I suppose.

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SerialKipper · 26/07/2012 10:09

With aggressive medical insurance companies, if you fail to report something, they can use it as the basis to declare the entire policy invalid, even when you're claiming for something completely unrelated.

So eg failing to report asthma could mean not being covered for a car crash.

US insurance companies certainly used to have whole departments investigating full medical histories when an expensive claim comes in, in the hope of getting out of paying. Michael Moore's film "Sicko" (2008) includes testimony from people who used to do that as their job.

I have an idea this may no longer be legal in some states, but you really do need to look into it. The fact that DD has had a hospital admission will make it hard to deny all knowledge.

DontEatTheVolesKids · 26/07/2012 10:20

I don't see how you can declare asthma if she hasn't a formal diagnosis.
I suppose you could honestly say she's been investigated for asthma, or that she's had VIW, but I wouldn't volunteer those things if not asked directly about the possibility.

It seems to me you'll have the easy option to move back to UK if your set up turns out to be pants.

Want2bSupermum · 26/07/2012 13:52

Get your DH to ask for the healthcare insurance documents and read them through. I do this every year and always find some little nugget of new information. Check if you need to name who your primary care physician is and what criteria if required for an ER visit to be deemed necessary (I got it out of the insurance company that if the dr says to go to the hospital then the visit will always be deemed necessary).

I have never had to declare a preexisting condition and don't know anyone who is an employee for a mid to large employer who has. Emergency room treatment has become very expensive. We joined a larger paediatrician group which is open 8am-9pm Monday through Friday and 8am through 3pm on Saturday. When DD was running a fever on Memorial Day (national holiday where everything else shut down around here) the Dr on call opened up for us and we paid the regular copay of $30 instead of 20% of an ER visit (wld have been $800-1000).

You will have an obn for your well women visits. They do PAPs annually here and my obn does a HPV test as well. The obn visit is consider a specialist so $50 instead of $30 for me. Being pregnant the copay is $50 for the first visit, $50 for the delivery and then you pay for the hospital stay (our policy is $500 a day up to $2500).

For any prescriptions get thee to costco, target or walmart. The savings are huge. We use costco and the savings are insane. If a drug is expensive ask the dr for samples.

We have an expat insurance that pays for all copays but I still like to keep the bills down so we don't end up out for so much money. If you don't have coverage for a procedure ask the billing department for a discount. I learnt an awful lot about the billing practices when auditing healthcare companies... Those huge bills that people talk about are not paid in full by the insurance company. The dr bills everyone the same amount and then insurance companies pay about 30% of the bill with the dr writing the rest off. The dr has to bill everyone the same amount for a procedure. If you have to pay out of pocket make sure you get a discount.

Moknicker · 26/07/2012 15:22

Thanks all. Do you pay into a healthcare escrow account which is tax deductible as well. What amounts are the norm for these.

The discharge letter states a diagnosis of VIW but explains the situation.

Want2 bsupermum - In my book you are. That was a fab post and the most useful info I have seen on the US healthcare system to date (and I have done a LOT of googling).

DH is with a mid to large employer so I hope that declaration or lack of it will be a non issue to the insurance company. However, presumably we can submit everything to the new docs in the US with respect to past medical history.

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7to25 · 26/07/2012 15:32

we had a bit of a problem in that we had to have a named primary care physician to take us on before our healthcare was valid (through my husband's employment) I found it almost impossible to get this done and had to call in favours from his colleages! I remember shouting at some receptionist
"I am a personal friend of DR X" I wasn't but by that stage had become desperate.

Want2bSupermum · 26/07/2012 16:01

Thank Moknicker I do try but fail more than I succeed! I have spent a fair bit of time finding out about what is available because I had the same concerns that you have when moving over here as a single young adult.

I think the escrow account you are referring to is the health savings or flexible spending account. There are a couple of differences between the two accounts. A flexibile spending account is limited to $2500 each year and if you don't spend it during the year you lose it. A health savings plan is for those with high deductible health plans. Very few employers offer the HSA - most do the flexible spending account. The IRS website goes into further detail about healthcare plans and healthcare accounts - publication 502 and 969

7to25 That came in last year for us. We didn't have a problem with it and we were in the middle of changing doctors. It is a stupid rule because most practices have more than one PCP that you will see more than the one named dr.

clarejane · 03/08/2012 04:45

Just to add - re declaring your child's possible asthma - I am in NYC and no expert on health insurance but I do know that Obama's recent changes to healthcare mean that insurance companies can no longer deny coverage for a pre-existing condition in children. So shouldn't be an issue one way or the other - but double check!

mathanxiety · 03/08/2012 06:13

Make sure your DH's insurance is comprehensive and not just bare bones, emergency room type coverage.

If it is comprehensive make sure you have a low deductible (under $500 annually for the family would be fantastic) and a low out of pocket limit (below $500 would be really good).

An 80/20 policy where the insurance pays 80% and you pay 20% of any bill is the usual but government employees above a certain grade get much better coverage.

Make sure the comprehensive coverage includes maternity and well woman checkups for you. A lot of private insurance specifically excludes maternity. If there is even the slightest chance you might become pregnant you should have maternity coverage. Ask when the coverage kicks in if maternity is included. Some policies restrict coverage to one calendar year after the starting date of the policy. Ideally, you should have maternity coverage and it should be usable from day one.

If you think you are pregnant when you get there definitely do not declare it until you get coverage. You will have to make up something fairly harmless like monthly spotting to cover your tracks.

Make sure the policy covers well child visits and covers all immunisations, not just sick child visits. I don't think you should declare the asthma -- don't know if the Obama changes have kicked in yet and I don't know if those changes would apply to people in your sort of visa position. (AM NOT AN EXPERT).

Insist on dental and optical coverage too. Medical doesn't usually cover dental, and eye care is often not included either. Make sure prescriptions are covered. Again, 80/20 is a reasonable split of costs. Sometimes there is a prescription co-pay of something like $10 for Rx -- depends on the plan.

Don't accept anything less, insurance wise, from whatever company is employing your DH. Health insurance is normally considered part of the remuneration package and subject to negotiation. It comes out of the employee's pocket ultimately but the employee gets a better deal than an individual trying to buy the same coverage because of the bulk aspect of the deal when the employer negotiates with the insurance companies, and because normally the employee doesn't have to submit to blood or urine testing as an individual would if trying to buy a policy.

YYY to the cheap pharmacy suggestions. Walgreens is good too but I don't know if they are in DC.

You can pay off your portion of a bill monthly with most medical care providers.

If your insurance has a preferred provider option you choose your doctors from a list the insurance provides and they will charge you a rate agreed with the insurance company. Your coverage will be pretty much assured for normal care, with no hiccups. You will choose an OB/GYN for yourself and a pediatrician for the DCs. Your DH could probably go to a Family Practitioner, or choose a specialist for whatever ails him. Best to choose doctors with admitting privileges in a really good hospital -- teaching hospitals tend to be good.

Health savings accounts are different from health insurance. You would need to be able to set aside a small fortune and cross your fingers really hard that nothing serious would go wrong in order to use one.

You will have auto insurance as well as health insurance, and your auto insurance policy will cover med expenses up to a certain limit as a result of a crash. You have to buy auto insurance yourself. It is generally not included in any employer plan unless there is a company car involved. So health coverage and car insurance are not linked normally.

Get yourself a nice big file labelled 'medical/insurance' and vow to keep it in order.

If you have DCs who will be starting school (Kindergarten) there are mandatory vaccinations in most states in the US.

ljny · 03/08/2012 06:16

The pre-existing conditions clause of Obamacare takes effect in 2014.

For most of your questions - health insurance policies vary widely. Get advice from the HR department in your husband's company.

You probably don't want to pursue an unnecessary diagnosis on the eve of your move to the US. If you follow my drift.

You can discuss relevant background with your child's pediatrician when needed. At your first visit, they'll give you a lengthy form to fill in that includes previous diagnoses - this is the doctors, who are separate from the insurance companies, but you may not want the doctor's claim to the insurance company for payment to claim for continuing treatment of an existing condition.

Yes, it's complicated. And Obamacare is a patch not a cure.

mathanxiety · 03/08/2012 06:22

If you have to reveal past medical history to the employer when enrolling in the health insurance and omit the asthma, then you should not tell the pediatrician about the asthma either. Wait until the DC has an attack and have the pediatrician diagnose it, which you could explain by different pollen, different mould, etc. Chances are you will not have to declare anything to the employer or fill out anything but name, sex and date of birth.

When filling in forms in the US, the order is Month, Day, Year - do not get birthdays wrong as a lot of delay can result when filling prescriptions or looking up records, booking appointments or talking to a doctor's office over the phone; a lot of doctors' offices and pharmacies identify patients by birthdate.

clarejane · 03/08/2012 12:50

No, children are covered for pre-existing conditions as of 2010 - the 2014 deadline is for when insurance companies are no longer allowed to deny anyone coverage for a pre-existing condition.

www.healthcare.gov/law/features/rights/childrens-pre-existing-conditions/index.html

kodokan · 09/08/2012 17:52

Our company healthcare is different to the copay-type ones listed above. It's a high deductible model, where we have an excess that we have to pay before the insurer coughs up. Ours is $3k per person or $8 per family, whichever limit we hit first. Preventative stuff is free, so we get well person check ups with blood work once a year, all vaccinations, screening such as Pap smears, etc.

So this means, for example, that when we took my daughter to the docs for an ear infection, we got a bill a month or two later - cost for the consultation and antibiotic was a little over $100.

We also have dental, which includes all the basic stuff like check ups, fillings and cleanings, and we make a 20% contribution to more complicated stuff - I paid $200 towards a crown recently, with the remaining $800 or so going to the insurer. My son is currently in braces, and our cost towards this is about $2000, spread over 2 years.

If you have a high deductible insurance plan, you can also have a Health Savings Account (HSA). You set an amount to be paid into this each month from your pre-tax wages, like you would with a pension in the UK, and can then use it for any medical related expenses. So we use it to pay for the sort of things outlined above, along with new glasses and contact lenses for me, that sort of thing (it can't be used for over the counter stuff like paracetamol, just things for which you've seen a 'doctor' of some sort). It's really easy - it's just a bank account with a debit card, so you pay electronically like normal, and then keep the receipt in case the IRS ever ask you to justify your expenditure to make sure it's genuine and you didn't use it for that month's groceries.

Because HSAs are funded pre-tax, it makes these costs about a third cheaper in real terms. You can put in up to... um... about $6k a year, depending on single or family, and any money unspent rolls over to the following years. We're planning to fund ours up to the level of the deductible on our insurance, then stop.

More and more companies are going down the high deductible/HSA route; my husband's, a large multinational, has just introduced this system in 2012. The idea is the govt/company wants you to (a) stop bothering the doctor for trivial stuff - if you only have to pay a $20 copay, you can pop in weekly for no real outlay, AND stay and chat for ages. Now, you're paying for the whole consult, so you'll only go when you need to, and be out as quick as poss without a bunch of reassuring but largely unnecessary placebo tests. And (b), they want you to have built up a HSA cushion to pay for some healthcare needs when you're old.

There are some tweaks to the model, where you pay a little more or less in premiums depending on whether you agree to name a doctor, or use their in-network doctor they allocate you (we did this, and have been delighted with the extensive, modern clinic we got; appointments are easy to get, the doctors are great and the clinic is like a mini-hospital with out of hours emergency care and the ability to run tests up to MRI level!).

As far as I'm aware, if your company offers this model, then that's what you'll have - certainly in our case it was a choice of take the company insurance, or arrange our own; there was no ability to negotiate or amend beyond 'do you want to save money by using our network doctors?' and 'do you want to add family dental for around $10-15 a month?' (your answer to that one should be 'oh yes!'). It's a little tiresome if you're healthy with no chronic conditions, because barring an accident you'll just be paying out the premiums and never seeing any benefit from run of the mill illnesses. Conversely, those premiums are of course cheaper, as the insurer knows a lot of people won't be claiming anything back, and are just insured for 'the big one'.

howdoo · 09/08/2012 22:51

kodokan, so glad you explained the high deductible insurance - this is exactly what we have, but I didn't think I could explain it properly! We have a 5k deductible, so we pay everything up to the 5k and then the insurance would kick in and pay for everything (I think) after that. However, it is not as bad as it sounds because 1. we use the HSA to pay the medical expenses and 2. the insurance company has already negotiated a (sometimes very) lower rate with the particular dr you see. Eg I got a dr's bill recently which was 150, but my insurance co. had negotiated with the dr before, and the bill is only 93. And TBH this is a low discount.

And your premiums are lower than the lower deductible schemes. We did get a choice of deductible size.

I think of these types of medical insurance as "proper" insurance IYSWIM - ie you will pay your premiums each month, but if something really bad happens, the insurance will pay out for everything (over a certain amount). So it's not that different to buildings insurance etc.

dreamingbohemian · 09/08/2012 23:09

Are you going to be in DC proper or the burbs?

I used to live in DC and it's generally a very good town for health care in that there are loads of good doctors, specialists and very good hospitals.

You should also check the insurance regarding specialists -- whether you can go to them directly or need a referral from the GP. Usually you can go directly, which is terrific.

I think usually if you get insurance through your employer, you don't need to worry about being penalised for preexisting conditions. I would not try to hide anything, if it comes out somehow you'll be really screwed.

You hear so many bad things about the US system but if you have decent insurance it's actually pretty great. I know the NHS can be good too but there have been many times it had me in tears and I longed for my old US health care.

Moknicker · 13/08/2012 10:40

All,
Just back from holiday hence the silence. Thank you all so much for the explanations and the advice. It is very useful. We are going to be in the NoVA suburbs - Falls church, mclean, vienna - depending on where we can find a house to rent. I will PM separately for recommendations regarding paediatricians.

We dont have a formal asthma diagnosis as yet, just an episode of viral induced wheezing, so i will avoid going for a formal diagnosis till next month so that we dont get into any trouble.

Kodokan thanks for explaining the HSA. Does an HSA make sense even if we dont have a high deductible?

Ive got the brochure for the healthcare plan so will be poring over it I suspect a lot over the next month.

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