r/HealthInsurance Oct 04 '24

Questions Answered: Which Plan Should I Choose?

28 Upvotes

Which Insurance Plan Should I Choose?

We get it, insurance is confusing, and you have ALL KINDS of questions when it comes to answering, “Which insurance plan is best for me”. Hopefully, this guide can provide you with some guidance and answers.

 

Decide on what is most important to you when it comes to Insurance- what factors into “the best” plan for you?

-          Financially, I want to pay the least amount out of pocket

-          MY Doctors-Having My preferred doctors in network

-          MY Medications-Making sure my medications are covered on the plan

-          The Type of Plan- PPO, HMO, EPO, POS, HDHP and their pros/cons

 

FINANCIALLY-

The entire point of insurance is to transfer financial risk from yourself to the insurance company. This is done in the form of your Out-of-Pocket Max (OOPM). The OOPM is the most your will pay for your care for all in-network, medically necessary (no cosmetic or elective things), non-excluded care (check your contract for excluded services).

The only way to figure this out "definitively" which plan is best Financially is to do some math.

Two schools of though.

1- What's the best plan should I hit an out-of-pocket Maximum. People RARELY plan to meet their OOPM, but it happens. Maybe you are on a health journey and planning for a big medical expense year with the birth of a baby, an upcoming surgery, or you just need a lot of care. To find out which plan is best via this method, you figure out the Maximum Financial Liability.

  • Take your Annual Premiums
  • Add the In-network Out of Pocket Maximum
  • If it's an employer plan, subtract any money the employer contributes to an HSA/FSA/HRA, because it's free Money

Compare the Max Annual Financial Liability of each plan you're considering. The plan with the lowest total will mean the least out of your pocket if you hit an out-of-pocket maximum- large claims, surgery, birth of a baby, etc.

2- If you want to plan as if you won't hit your out-of-pocket max, the only way to do this is to spreadsheet out what your anticipated year of care looks like. How many Dr. Visits, how many prescriptions you take, any planned procedures, etc. You will then have to guestimate how much these things will cost you out of pocket. You may be able to get a general idea of the cost by looking at the allowable amounts on your old EOBs- Explanation of Benefits.

This method involves some guessing and some additional research to end up at an imperfect budget estimation, so that's why I prefer the Max Annual Financial Liability Method. It's straight math that helps you prep for the worst possible scenario. If you don't end up hitting an out-of-pocket max, you can rejoice that you are below budget. If you do hit an out-of-pocket max, you can rejoice that you picked the right plan from the start.

 

 

 

MY DOCTORS-

Every insurance plan has a list of doctors that are considered in-network. You likely will be able to check this list even before signing up for the insurance plan. Be sure to visit your carrier website to check for the provider list. When searching that list, be sure you are searching for YOUR network. Doctors may be in network with some BCBS/UHC plans, but not others.

It’s also generally a smart idea to call the provider and verify network status as the Provider Lists can be out of date/incorrect for a variety of reasons. It is always YOUR responsibility as the member to check Network Status of a doctor. They don’t always inform you if they’ve left a network, and, unfortunately, they aren’t mandated to do so yet.

When verifying network status, ask “Are you in network with my insurance network”- and provide the exact network name of your plan. A doctor may be in network with some BCBS networks, but maybe not YOUR specific network with BCBS. Most providers “accept” most insurance, but you will not get the in-network discounts/allowable amounts if they are not actually IN your network.

 

MY MEDICATIONS-

Every plan has a Prescription Formulary List. You can obtain a copy from your Carrier by contacting them, or it may be listed in your insurance portal. If you obtain your insurance from your employer, you may be able to ask for this information from your HR staff/Broker.

This Rx Formulary List will list out all the medications they cover, what tier the medications are, and any special information about that medication such as:

-          dispensing limits

-          if Prior Authorization is needed

-          if they are only for certain conditions

Do note that formulary lists can change, even during the plan year. There are always options for appeals, depending on the specifics of your plan.

Some plans may also require you to obtain medications from certain pharmacies. Specialty Medications are a common one to require you obtain them from a Specialty Pharmacy via mail order. If it’s important to you to be able to pick up your Specialty Medications from a local pharmacy, you may not want to pick a plan that requires the use of a mail order pharmacy.

 

TYPE OF PLAN-

When it comes to the different types of plans that may be available to you, it can almost feel like you’re eating a bowl of Alphabet Soup. PPO, EPO, POS, HMO, etc. Here are some resources to help you differentiate between them.

-          PPOs- Preferred Provider Organization

-          EPOs- Exclusive Provider Organization

-          HMOs-Health Maintenance Organization

-          POS Plan- Point of Service Plan

Handy charts noting High Level Differences:
https://www.simplyinsured.com/advice/wp-content/uploads/2016/10/table-1-health-insurance-networks-768x818.png

https://www.opic.texas.gov/health-insurance/basics/comparison-chart/

https://www.uhc.com/understanding-health-insurance/types-of-health-insurance/understanding-hmo-ppo-epo-pos

HIGH DEDUCTIBLE HEALTH PLANS (HDHPs and HDHP-HSAs)-

These are a further subtype of plan that may be available to you. Most commonly, we see HMOs and PPOs that are also HDHPs. These plans are designed to have you meet your deductible before insurance will begin paying for any of your care (except ACA Mandated Preventive Care on ACA Compliant Plans). Many people opt for these kinds of plans without realizing this important factor, as it’s often the most affordable plan offered by your employer, and we all know we’re looking for fewer dollars to be deducted from our paychecks.

You will still get a network discount for your in-network care, but you’ll pay the full contracted rate for your care before you meet your deductible THEN your coinsurance percentage will kick in.

Example- You have a PCP who bills $600 for a PCP visit. If they are in- network, the contracted rate may be more in the $125 range. If you have an HDHP plan, you will pay that full $125 every time you visit your doctor. Once you hit your deductible, you will pay your Coinsurance percentage of that contracted rate, until you meet your out-of-pocket max. So, if your coinsurance percentage is 20%, you’ll pay $25 for a PCP visit, after you’ve met your deductible.

Many first timers to HDHP plans get a little bit of a sticker shock when they get their first EOB-Explanation of Benefits- from insurance and see that, while they got a network discount, insurance didn’t pay anything towards the balance. This is how the plan is designed. So, if you need the comfort of, say a $30 copay each visit, from the start, an HDHP plan may not be for you.

The trade off with HDHPs is that many (BUT NOT ALL) HDHPs allow for you to open an HSA- Health Savings Account. These are bank accounts are designed for you to contribute money on a pre-tax basis to a special account you can use to help pay for your care. You can use the money for payments towards your deductible/OOPM/Coinsurance/Copays, your prescriptions, your Durable Medical Equipment and even some over the counter items.  Here is a list of qualified purchases with an HSA.

The HSA funds are yours to keep and use whenever you’d like. Today, Tomorrow, 10 years from now. The funds never expire (like they do with an FSA- Flexible Spending Account). However, do note that there are some rules to be eligible to open and contribute to an HSA:

  • You must be enrolled in an HSA-Compatible HDHP.  
  • You must not have any other health insurance coverage that is not an HSA-eligible HDHP.
  • You may use the accumulated funds to pay for your care, even if you are no longer enrolled in the HDHP in the future. You may not use the funds to pay for care before your HSA was opened. No covering past bills.

Taking your HSA further: INVESTING
(this is not a financial planning subreddit, feel free to direct investment questions to one that is)

-          Many banks will allow you to invest your HSA dollars so they can grow tax-free. You will need to consult with your HSA vendor to inquire about investment opportunities. There may be minimum thresholds to invest or a small fee to use guided investing tools/advisors.

-          Pay yourself back later. You may decide to pay for your care out of your normal checking account. Keep those receipts and pay yourself back later, once you’ve made a profit investing your HSA funds. You can reimburse yourself immediately, next year, 5 years from now or even after you retire. You should keep your receipts in case of an audit though.


r/HealthInsurance May 06 '25

Guide: Was I scammed!? Where do I buy actual health insurance!?

17 Upvotes

Looking for individual / family health insurance?

Start with healthcare.gov -- that's it. Start there. If your state operates their own marketplace, healthcare.gov will let you know and give you a link.

Remember: policies sold through healthcare.gov are all ACA-compliant. These policies guarantee coverage of pre-existing conditions. These policies include "out of pocket maximums" or OOPMs (or MOOPs). These policies are bought and sold during the annual enrollment period (federally, that's November 1 - January 15, some states have slightly different enrollment periods, but they're all around this general timeline). You can also purchase a policy through healthcare.gov outside of open enrollment by experiencing a qualifying life event.

If you are outside of open enrollment and have not experienced a qualifying life event yet still purchased an insurance policy, chances are it's a non-ACA policy through that shady website / broker you just used. If you spoke with an agent / broker and you had to answer a detailed set of questions regarding your health history during the application process, chances are you bought a non-ACA junk medically underwritten policy.

If you suspect you've fallen into a junk policy, make a new post and share the details of the coverage you purchased--where did you get it from, how much does it cost, what state do you live in, what's your gross annual income, etc.


r/HealthInsurance 1h ago

Employer/COBRA Insurance Had a “free consultation”, and then got billed $2400 for an office visit

Upvotes

I had a free consultation with a doctor to discuss treatment plans he offers. Everything sounded good, so I agreed to give him my insurance information. Then I find out that he billed $2400 to my insurance for my “free consultation”. I believe this to be a fraudulent charge.

What do I do? Can I get my insurance company to fight the charge?


r/HealthInsurance 1h ago

Claims/Providers What can we do about this reported rise in inaccurate provider directories?

Upvotes

It’s one of the things I consistently see here and you can’t verify each and everyone so how do we keep insurers accountable as there is much confusion?


r/HealthInsurance 2h ago

Claims/Providers Provider charging more than EOD

1 Upvotes

I have a once-a-month phone visit with my psychiatrist. Since January, I’ve been charged $130 for each visit. The psychiatrist claims this is because I haven’t met my in-network deductible. However, none of the money I’ve paid has been applied to my deductible. My Explanation of Benefits (EOB) for each visit shows that my responsibility is only $25.

I have Cigna, and my psychiatrist is in-network. It’s a one-person practice, so there isn’t a billing department to work through. I remember this same issue happening last year before I met my deductible. At that time, I contacted Cigna, and they must have reached out to my psychiatrist because he called me to say I was being charged $130 due to not meeting the in-network deductible. Later, I got sick and met the deductible, and my responsibility dropped to $25 per visit, so I let it go.

Claim 1 * Amount Billed: $250.00 * Cost Reduction: $156.43 * Amount Not Covered: $0.00 * Allowed Amount: $93.57 * Copay: $25.00 * Deductible: $0.00 * Plans Liability: $68.57 * % Paid: 100 * Coinsurance: $0.00 * What I Owe: $25.00 Claim 2 * Amount Billed: $150.00 * Cost Reduction: $110.00 * Amount Not Covered: $0.00 * Allowed Amount: $40.00 * Copay: $0.00 * Deductible: $40.00 * Plans Liability: $0.00 * % Paid: 100 * Coinsurance: $0.00 * What I Owe: $40.00 Totals * Total Billed: $400.00 * Total Cost Reduction: $266.43 * Total Amount Not Covered: $0.00 * Total Allowed Amount: $133.57 * Total Copay: $25.00 * Total Deductible: $0.00 * Total Plans Liability: $108.57 * Total Coinsurance: $0.00 * Total Owed: $25.00

Am I due a refund? What do I do from here if it is illegal?


r/HealthInsurance 2h ago

Plan Benefits UHC insurance with HRA account - help explain

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1 Upvotes

My husband’s company switched insurance mid year…. We now have United healthcare insurance and the employer has up sign up for and HRA to reimburse us up to $12,700 for medical, $1000 dental and $500 for vision.

We have a family plan.

This was in their email offer letter:

United Healthcare Co-Pay & Deductible Medical Insurance Plan for Employee and Family at No cost. We reimburse all in network co-pays, prescriptions and deductibles for the employee and family. Dental and Vision Insurance Plan for Employee & Family at no cost to employee Plus reimbursements of Dental expenses for Employee Only at $500, Employee & Family at $1,000 Reimbursements of Vison expenses for Employee Only at $250, Employee & Family at $500

I am so confused because their big thing was that everything is covered, from having a baby to brain surgery….?

Anyone help me decipher this please 🙏🏼


r/HealthInsurance 3h ago

Plan Benefits Anthem BCBS COBRA -> ACA; out-of-pocket max, prior authorizations

1 Upvotes

Our family has been on an Anthem BCBS high deductible PPO plan via a former employer for 17 months. We lose access to it at the end of September.

There is an ACA Silver 73 Anthem plan which appears to have similar terms at a similar price. We have on the whole been happy with Anthem and are inclined to switch to it.

Because we've been on an employer's Group plan, we would be switching to an Individual Member plan through the ACA and would this seems to be a big jump within Anthem. When I call the question line for our Group plan they route me over to Sales to talk about an Individual Member plan.

So I have two questions for anyone who has done this:

  1. With group plans at open enrollment in July each year if we switch plans, any money we've spent out-of-pocket so far that year counts toward the out-of-pocket maximum on the new plan. So if we spent $1000 before Open Enrollment, the new plan which starts after July will count $1000 toward the out-of-pocket max. Is that also the case if we switch from a Group plan to an ACA plan? I'm afraid we'll reset to $0 and end up paying a lot out of pocket.
  2. Will prescriptions which required a prior authorization on the Group plan need a new Prior Authorization on the ACA plan? I assume yes. Are they more likely to be denied on an Individual plan?

I've tried asking these questions of Anthem, but I get routed to their sales department who focuses on trying to sell us on a non-marketplace plan. I didn't get answers to the questions I most wanted answered.

Edit: Family of 5, parents in our 50s with three teenage kids, in California. About $70k gross income right now.


r/HealthInsurance 1d ago

Plan Benefits I had preauthorization and now I owe $27,000 because Oxford won’t cover it

45 Upvotes

I’m honestly besides myself and I don’t know what to do. I had Preauthorization from my insurance covering egg freezing and now Oxford is saying that Cornell are billing the wrong code and that they won’t cover it.

Oxford is saying “its denied due to the provider billing a procedure code that was not approved by the prior authorization s4021”

Cornell is saying “that the codes S4020 and S4021 are not reviewed by the insurance. The billing code used S4021 is correct with our contract with the plan in treatment cycle”

I’m absolutely beside myself. I don’t have this kind of money at all and as a single mom of 1 going through cancer treatment this will bankrupt me. I can’t wrap my head around how this happens when I have preauthorization of coverage.

Has anyone else had this happen? I am beside myself.


r/HealthInsurance 5h ago

Employer/COBRA Insurance HSA Eligibility Question

1 Upvotes

Hi all, I’m trying to confirm HSA eligibility for 2025. I’ll be starting a new HDHP plan through my employer with an effective date in September. My parents’ insurance currently covers me.
If I set my parent coverage termination date to September 1, would I still be considered to have “other coverage” on that day and therefore not be eligible to contribute to my HSA for September? Or does it need to terminate August 31 for me to be eligible starting September 1?
Thanks for any clarification!


r/HealthInsurance 15h ago

Plan Benefits Is there a rule that the health insurance companies can't make their policies so hard to use they are unusable?

7 Upvotes

I need to see a therapist. The insurance provider gives me 500+ therapists in my area. But I've gone thru the top 50 and all of them are either: i) not really therapist but are say psychologists that deal with autism or not taking new patients.

Shouldn't it be on the insurance company to find me someone who is available. It seems they make their provider list so vague and so out of date this benfit is useless. I want to cite some rule that they must abide by.


r/HealthInsurance 11h ago

Plan Benefits dad needs help- dialysis patient newly diabled amputee diabetic

3 Upvotes

Hi All,

My dad has been battling a number of health challenges.
He was admitted to the hospital for right foot amputation infection which resulted in needing two toes amputated immediately. He was at Kaiser in Northern California. He then needed a heart stent to be strong enough for a leg bypass graft surgery. Which was then followed by removing the remaining toes which occurred in late July.

He was released from the hospital rather abruptly, and has since been in a post acute center. His is a diabetic, with stage four renal failure. He can't currently balance on his own at all, he's not able to use the bathroom on his own and has had few actual physical therapy for this recovery.

The post acute center decided it was time for him to leave this week. My family and I agreed this was ridiculous to even suggest as he is not ready at all to be home. Not to mention our home is not handicap ready yet. The risk was to file an appeal and stay there longer, but then if the appeal should be denied, we would then have to cover the major costs for his extended stay. The decision was made to have him stay with my sister and her husband, an hour away from his hospital, dialysis center, home, BUT its the only option for us now.

I am reaching out for several reasons,

a) Does anyone know what to do about this unrightful release of my dad? Legally speaking?

b) does anyone know of insurance resources that my dad may be eligible for regarding the handicap bathroom remodel, and ramp installation for front porch? Grab bars, handles, special shower, NOT SURE WHAT ELSE ?? Help there would also be GREATLY appreciated.

c) are there insurance coverages for home nurses, diabetic, dialysis equipment for the home with Kaiser Advantage? My parents are retired with this health insurance.

d) anyone have any good tips for helping him for the time being? We are pretty limited at my sisters house. as you can imagine also not handicap/ADA/post foot amputation operation ready.

Sending this out with true hope in my heart for some help. I appreciate any and all attention on this <3


r/HealthInsurance 6h ago

Medicare/Medicaid how to get a new insurance card???

0 Upvotes

i can’t find my insurance card i’m 19 and my parents won’t give me a replacement, i tried to call the customer service people but it kept asking for eitherer a member id or ssn which i have the ssn but it literally wouldn’t register like idk wtf is wrong with the system but i tried waiting and the robot voice operator just kept hanging up the phone i also tried to spam 0 but that also wouldn’t work how can i get a new insurance card? UMR


r/HealthInsurance 1d ago

Claims/Providers Doctor and insurance is now saying they are out of network despite my insurance website listing them in network and when I booked the appointment they told me they were covered by insurance - Please Help!

33 Upvotes

I am fuming. I went to a provider and when I booked the appointment they said they were covered by my insurance. They are also listed in my insurers (blue Cross Blue shield) website as in network. Now they and my insurance are telling me they are out of network and billing me $16k for several visits and an injection.

What are my options here - surely they and my insurance lying to me isn't legal? What can I do? I obviously never would have gone to them if they are out of network. Also they billed me 4 months later so I would see them several times.


r/HealthInsurance 17h ago

Dental/Vision Dental office filed my claim 7 months late, insurance denied, now they stopped my treatment until I pay — what can I do? (California)

5 Upvotes

Hi everyone,

I’m in California and need some advice about a situation with my dental provider and insurance.

  • Date of service: October 1, 2024 (tooth extraction at Irvine Oral Surgery)
  • Insurance: Ameritas
  • Filing rule: Ameritas requires claims to be submitted within 90 days
  • What happened: The dental office didn’t submit my claim until May 2025 (over 7 months late). Ameritas denied it for untimely filing.
  • Office response: They confirmed on August 27, 2025, that the claim was “submitted electronically” with the 90 days timeline, but refused to provide a clearinghouse report showing when it was actually filed.
  • Problem: The office is demanding that I pay the full denied amount out of pocket. They have also stopped my ongoing treatment until I pay.

From what I understand, filing the claim on time is the provider’s responsibility, not mine. I gave them my insurance information on the day of service. I don’t think I should be forced to pay for their administrative error, but I also need to continue treatment.

My questions are:

  1. If I pay now just to continue treatment, how can I recover the money later?
  2. Can I mark my payment as “paid under protest”? What if they refuse to accept that wording?
  3. Should I file complaints ? How can I do that?
  4. Is there a best way to solve this ?

I’d appreciate any guidance or similar experiences. Thanks in advance!


r/HealthInsurance 8h ago

Individual/Marketplace Insurance Please help me understand the marketplace!

1 Upvotes

Hello. I recently lost my job, and my new job does not offer health insurance. Therefore, I am trying to purchase a plan on the marketplace this weekend. I live in Georgia. I am on the website right now, and I am so confused. Can you please answer the following questions to help me understand what I am about to purchase? Thank you!

  1. What does CSR eligible mean?

  2. Why are some plans $0.00 per month? This seems too good to be true...

  3. What is the difference between deductible and OOP max? What does it mean if the deductible is 0?

  4. Is gold better than silver, which is better than bronze?

  5. Why is HMO my only option?

  6. Why is there a random price next to office visit and generic drugs?

I think what might be most helpful is if you could just walk me through an example (I posted a screenshot of a random option). Thank you!


r/HealthInsurance 12h ago

Claims/Providers Question on "adjustments" months after bill issued and paid

2 Upvotes

So I am struggling to understand what is going on. I had a remote doctor visit back in May, just the visit and nothing else. I was sent a bill for $233, with an insurance adjustment making the amount I owe $188. It was paid and i moved on.

this week in August, I received another EOB in the mail for that same visit. It has a different type of visit, and the bill is now for $290 with an adjustment making the amount $247, and stating I still owe the $59 remaining.

I have called both my insurance company and the hospital asking what is going on, and literally not one single person I have talked to will even touch my question. Why do i have 2 different bills with different amounts and different procedures on them? They all keep saying, you have a bill from this day and you owe $59. Thats it, they will not speak any other words. I have a paper copy and receipt of the original $188 bill, I have sent PDF copies. They dont acknowledge the PDF copies in any shape or form, and when i asked to speak to a manager, they said they dont have any records of it.

I found on the insurance website today a new issuance from 08/26/25. Its a carbon copy of the original issuance with the numbers changed, and a new box that says "adjustment" at the bottom just saying "date of adjustment 08/14/25.

Can someone PLEASE help me make sense of this insanity? I dont even care if it was a coding error and i owe more, SOMEONE should be able to tell me at least that much, but nobody will.


r/HealthInsurance 18h ago

Claims/Providers Do providers offer a "discount" for private pay?

5 Upvotes

My husband and I are very blessed to be FIRE (financially independent retired early). We have our health insurance through a small insurer we found through the healthcare dot gov portal. We've had them for about 3 years now and it has worked very well for us. A month ago I got a terrible stomachache. After about 10 hours and increasing pain we went to the local urgent care (it's large and calls itself a 'hospital'). I got great care and they did a CT scan right away. I got some pain killers and went home. (More tests are ensuing with a variety of doctors.) On my insurer's portal, I see that the Total charge for that visit was a whopping $32,800. My insurance paid $8.19 - yes, the decimal is in the right place. I only owe about $1,430.

My first question is, is the reason I only owe $1,430 because I had insurance and a giant chunk was "discount/disallowed" because of that insurance? One fee from that night was $18.8k and close to $18k was disallowed.

Second question. My same insurer did not approve an initial request for a PET scan for me (prior to an MRI). We decided to pay out of pocket and were told it would be about $3600. We said okay. But when we let the provider know we were doing it private pay, it suddenly cost us only $1800. Why?

I have some family members (young adults) that are uninsured and simply don't place a big value on health insurance so they don't spend what little they have on any of it. If they needed the same urgent care I did. What would they be looking at in terms of cost? Thanks for any info.


r/HealthInsurance 13h ago

Medicare/Medicaid So confused here, need a little advice if possible... THANKS!

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2 Upvotes

Okay, I have an insurance question here that is job related actually. I'm curious... I currently have Santa Clara Family Health Plan through Medi-Cal here in California.. I'm thinking about switching Santa Clara Family Health Plan to Blue Cross Blue Shield through Medi-Cal.... My question is... For my part-time job I do Uber Eats delivery driving and they offer a quarterly medical stipend, however Medicaid insurance is not accepted when applying for this stipend BUT it does say Blue Shield is. So I'm wondering, if I have Blue Shield through Medi-Cal is that going to be declined, or because it's Blue Shield do you think they would accept it??

Also, if it's not going to work, Is there a way to look up health nsurance plans and get rates WITHOUT someone calling you on the damn phone?? Cause I tried to do that once and you have to enter your information and then suddenly I was getting calls every day and I don't want that AT ALL...


r/HealthInsurance 21h ago

Claims/Providers Insurance Not Paying Claims

7 Upvotes

Nearly every one of the approximately 35 claims filed this year have the status listed as “EXC”, flagged for manual review. These claims go as far back as January, and include everything but dental claims. Urgent Care, TeleHealth, Primary Care visits, lab work - even scans and surgery that received pre-authorization. I’ve called the insurance company contact repeatedly, and have been told they’re “escalating” the situation, referring it to supervisors, that the supervisor has contacted claims and is waiting for a response, that things are delayed because of a new computer system. Well, their new computer system paid my dental claim from 4 weeks ago, and all my husband and kids claims from this year, but won’t pay my claims from as far back as January, 2 months before this computer system change? Today the customer service rep even told me that she’s never seen anything like this, and it’s definitely not normal. Computer system changes are not the issue.

Now the hospital has sent me a bill for the pre-approved surgery in May that insurance still hasn’t paid. And the lab my doctor’s office uses is sending me bills and text messages, saying that I may not be able to have any services from them until their bill - from MARCH - is paid.

We pay over $10,000 per year for medical insurance premiums, and now when we need it, they won’t pay the claims? And what—am I supposed to put my cancer treatment on hold until they decide to get around to paying them? I am beyond frustrated, and have other things to do than argue with insurance and try to figure out where and how to escalate this.


r/HealthInsurance 16h ago

Plan Benefits Is this trickery or am I stupid?

3 Upvotes

I hate insurance and can never understand how it works. I have been going back and forth with my insurance because I feel like they are lying to me about how this works but I may just be stupid. I thought any payments I made out of pocket were applied to my deductible, but they are telling me that it is just co-insurance. Can someone decode the bullshit babble?

Relevant info: Deductible: $1500

I had a pre-approved covered medically-necessary surgery in April. In March, I went in for my pre-op blood work. I paid the hospital up front $1100 based on the info they got from my insurance and I was super pumped that the rest of my surgery would be covered because that payment would surely get us to the $1500 with previous care throughout the year.

Well surgery is complete and a month later low and behold I get a bill for $1700 to my surgeon, my deductible plus $200 of coinsurance to the surgeon.

Insurance is saying that the $1100 didn't go to my deductible because the claim wasn't processed until after the surgeon's claim (they processed it in May), so that $1100 went towards my co-insurance instead.

Does that make sense to people who know insurance? Please be nice. They make this shit so confusing on purpose but


r/HealthInsurance 20h ago

Claims/Providers I need to verify how copays work

6 Upvotes

I have a provider who is new to owning their own practice so I’m wanting to confirm. I tried calling my insurance but I was unable to articulate my issue. Let’s hope I do better here

The person is in network for an insurance company who notoriously pays low.

They have their visit cost and I have a 10% copay for in network, they are in network.

I will put the amounts but if my provider reads this I’m just trying to make sure we don’t screw up.

Visit is $104 EOB says will pay $62.10 Says discount is $35 Total due from patient is $6.90

Provider wants copay to be an even $35 so that they get the entirety of what they billed. I was under the impression that the amount owed is all they can bill.

I personally wish I could pay this person that amount but I believe it may be against terms and conditions for the company they are billing.

Can anyone shed any light? Also please feel free to ask questions if I have explained things wrong. I also hope I picked the right flair.


r/HealthInsurance 21h ago

Plan Benefits Miscoded procedure sent to collections.

7 Upvotes

Months ago, my wife had an ultrasound, ordered by her doctor, to investigate abdominal pain. The insurance denied coverage. She investigated and it turned out that the hospital had coded it wrong. In other words they were trying to charge for a procedure that wasn't approved, instead of the procedure that WAS approved.

She went round and round with the doctor's office and the hospital, about who needed to recode the procedure. She finally got it recoded, and then the hospital kept sending her the bill. But she never got another EOB from the insurance.

She spoke to the hospital and asked if they had resubmitted the corrected procedure to insurance. They said they can't bill the insurance without her permission. (WHAT? They won't do a procedure without having your insurance info and your permission to bill.) So she told them "you have my permission. Please bill my insurance using the corrected code."

She still hasn't gotten an EOB from insurance. Yesterday she got a letter from a collection agency on behalf of the hospital.

Any advice on how to handle this? Collection agency wants a response or payment.


r/HealthInsurance 23h ago

Individual/Marketplace Insurance How do I get health insurance next month if healthcare.gov keeps trying to send me to Medicaid (which I won't be qualified for)?

8 Upvotes

Currently unemployed and on Medicaid.

Start a new job on Sept 1st that doesn't provide health insurance. Will make well over the amount that qualifies me for Medicaid. Have also moved to a different state.

Am attempting to use healthcare.gov to get healthcare for September. But because I put '0' for August income, despite that I've put $60000 for total expected annual income, it's telling me I'm being evaluated for Medicaid and won't show me plans available.

It's beyond frustrating. Do I just have to contact an insurer directly to purchase health insurance to ensure I'm covered on the 1st?

Edit: Never mind. I reapplied and told it not to check for savings, so it didn't ask me for income and just showed me plans. Presumably if I do qualify for savings (which is doubtful) I can get it back in my taxes. Leaving this up in case it's helpful for others.


r/HealthInsurance 12h ago

Plan Choice Suggestions Health insurance for a recent graduate.

0 Upvotes

I (27F) just graduated from ASU and live in Tempe, Arizona and my student health insurance plan is expiring tomorrow. I’m on F-1 status and my OPT just got approved recently, so I’m in this awkward gap where I don’t have medical insurance coverage yet.

I’m freaking out, please give me any suggestions on what plan to choose. I haven’t found a job yet, I’m still looking. I don’t have a lot of budget for it as well. Maybe 50-60$ a month max. Please help me out!!


r/HealthInsurance 13h ago

Plan Benefits Medical coverage out of state

0 Upvotes

Hello. I am seeking some advice.

I currently have Blue Care Network of Michigan HMO Silver Saver plan.

I am in Florida. Yesterday I was picking some tonsil stones out of my left tonsil (I know, gross) and last night I started experiencing pain when swallowing from that left tonsil.

Well today, the pain has been quite moderate when swallowing, and I’ve felt nauseous all day including a headache that isn’t going away with ibuprofen, and I’ve only been able to lay in bed all day. I’m wondering if I injured the tonsil and may have an infection.

If I wake up and symptoms persist tomorrow, I am going to go to a med center/urgent care.

However, I’m not sure about having coverage out of state. I know I can call customer service and ask but depending how bad I feel I might really need to get to the doctors as soon as possible.

My deductible and max out of pocket are both met.

Thanks for any and all help.


r/HealthInsurance 14h ago

Plan Benefits Stressful Billing Nightmare: Urogynecology Swabs Suddenly Denied

1 Upvotes

TL;DR: Had vaginal swab tests at a hospital clinic. May test ($285) covered, July tests ($285 each) denied as “investigational” after insurance policy change. Hospital portal shows $0 responsibility, but insurance denial still listed total patient responsibility $570. In-network providers aren’t required to write off non-covered services—so might get billed anyway. Any advice on handling this or avoiding surprise charges?

I had vaginal swab tests at a hospital urogynecology clinic this year. The first one in May ($285) was covered. Two later tests in July ($285 each) were denied as “investigational” after an insurance policy update.

The hospital portal now shows $0 patient responsibility, but insurance still lists the claims as denied with total patient responsibility $570, and I’m worried about surprise bills. Insurance reps say in-network providers aren’t required to write off non-covered tests—so whether I get billed is up to the clinic.

It’s frustrating because I followed all rules, and the tests were recommended by staff. Has anyone else dealt with in-network providers giving tests that became non-covered mid-year? How did you handle denials vs. potential balance billing? Any tips to avoid ending up on the hook financially?


r/HealthInsurance 22h ago

Plan Benefits Is my PCP correct that the hospitals HAVE to use motor insurance for a car related accident?

5 Upvotes

I got into a car accident at the fault of another driver.
I m trying to get myself checked, but my PCP told me that if the hospital sees that this is an auto accident related examination, it will be denied and that I should use my motor vehicle insurance. My motor insurance says that my primary health insurance should cover it.

Is that correct?

EDIT: It looks like this is more case by case basis. Didn't know it can be this complicated. Thank you.