and now, my second moment of panic today

[kindkit]

Medical billing is an obscure and arcane branch of sorcery, y/y? Certainly it involves trafficking with the eldritch horrors that are insurance companies.

This post brought to you by the fact that I got my prescriptions delivered just now, and it looked to me like I had been billed $508.87 for the testosterone prescription that last month cost me about $22. This change was due, apparently, to the fact that my insurance company has finally started covering this prescription. Naturally, this should lead to my paying $500, right? I guess that's how insurance works?

One angry phone call to my pharmacy later, it turns out that I have not been billed $500. It . . . has to do with co-pays, and how my insurance covers prescriptions, and apparently my insurance company wants me to pay $500, but the pharmacy is waiving all but $22 of that but this will still cause a credit of $500 to go towards my deductible . . . ? I guess . . . ? Anyway, I don't owe anybody $500 for one month's worth of testosterone. I guess.

I feel shaky and tearful, and also guilty for being so angry on the phone before I understood. The folks at the pharmacy have always done their best for me, which is part of the reason why it was such a shock.


Explanatory thingy for those blessed people not in the US who don't have to deal with this shit: so, we lucky, free Americans who have health insurance pay towards it every month. I am lucky in having generally extremely good insurance* through my job, so I pay less than $100 per month; others pay hundreds or even thousands monthly, if they can afford it at all. [*Generally really good except that they want to discriminate against trans people even though that's illegal in my state.]

So, having paid your monthly bill, all your medical expenses are covered, right? Not so fast. Nope. First, health insurance has a deductible, which is the amount you have to pay before insurance will cover anything*. In my case, because I have insurance that I've literally heard an insurance broker express envy of, my deductible is $500. For those with less enviable, but still normal, insurance, it's $5000 or more. [*Except certain kinds of routine visits, and some prescriptions, and . . . it's all really fucking confusing, okay?]

So, once you've paid the deductible, you're good, right? Nope. After the deductible, the insurance will pay a certain percentage of the bill, but you keep paying the rest, until you've reached your out-of-pocket limit. This and the deductible are annual, and reset every year. My out of pocket limit is $1500, +$500 deductible = $2000 yearly. That's the most I will ever have to pay.

Except for the co-pays, of course. Insured people still have to pay a fee, typically around $20 to $30 but sometimes more, to see a health care provider. There's also a co-pay on prescription medicines. Mine is supposed to be $10, or $20 for certain less common drugs, but in practice it seems to vary widely. Sometimes it's $0, sometimes apparently it's $500.

Gibbering in cosmic terror yet? I haven't even mentioned the whole "in network vs. out of network providers" thing (basically, you pay a fuckton more if you make the mistake of going to a provider who doesn't have a contract with your specific insurance company). There are horror stories of people getting hit with huge bills after surgery because the anaesthesiologist, who is generally assigned by rota that individual patients have no say in, turns out not to be in their network. I also haven't mentioned separate deductibles and co-pays. My insurance, which let me reiterate is really good, has a completely separate system of deductibles and co-pays for physical therapy, and also I believe a separate one for MRIs. Both of these things have deterred me from seeking treatment for what's probably a rotator cuff injury in my left shoulder.

Some insurance plans also have coverage maximums. If you hit that maximum, well, good luck to you! They won't pay any more towards your cancer treatment or your catastrophic brain injury that year.

And this is the system that many Americans, not all of them right-wing politicians, insist is the best in the world.

Comments

[mllesatine]

Whenever I finished one paragraph I felt I finally got a grasp on American health care only to find out that it's still one more fee, co-pay, deductible. Up until now I always thought deductibles are some goal you work towards with your taxes.

I'm trying to find the German equivalent because we do have that kind of thing here. You have to pay a fee for hospital stays (capped at 28 days a year), prescription drugs, aids like wheelchairs etc and when you reached a certain limit and kept all the receipts you can ask your insurance to calcualte your out-of-pocket limit (based on income, usually 1 or 2% of your gross salary) and they will pay you back the amount you overpaid. I guess this is sort of how your prescription drug now works?

I think it's incredibly hard to even compare health insurance from country to country. You really have to have experiences with the systems and how many people can say that they were sick in two different countries?

[kindkit]

That sounds like it's still much less of a financial hardship than the US system. The out of pocket limit on my insurance--and I have very good insurance by US standards--comes to a lot more than 2% of my gross income.

Literally thousands of people in the US declare bankruptcy every year because of medical bills they can't pay. No one knows how many more just don't get needed treatment.

I'm nothing like an expert, but from what little I do know, I support a system like the NHS in the UK--paid for by taxes, completely free at point of service. There's enormous cost savings in not having all those layers of administration to deal with billing, not to mention in eliminating insurance companies and their billions of dollars in annual profit extracted from sick people.

The NHS isn't perfect--apparently it doesn't include either dentistry or mental health care--but it seems like it worked pretty well before successive Tory governments started under-funding it to death.

[mllesatine]

Absolutely. I just used the examples of the German system to muddle my way through the American one. :) There are the same kind of deductibles in play but the German ones are much lower.

[lilacsigil]

I am super glad that I do not work in pharmacy in the US (quite apart from the ethical questions). The bureaucratic side here is tricky enough dealing with just the government, I'd hate to be dealing with the government AND 5000 different insurance companies.

[kindkit]

My pharmacy has a specialist on staff just for dealing with insurance companies.

[silveradept]

US health insurance is such a nightmare, and is also the reason a lot of people are stuck working where they are, because not working means no insurance and everything costs whatever the provider or company thinks they can get you to pay, even if it's more than you'll ever make in your lifetime.

(Because the horrors go deeper still, friends with sensible health systems.)

[kindkit]

Yup. I'm glad that I don't hate my job, most of the time, because if I did I would still be reluctant to leave since the insurance is so good.

I've sometimes wondered why businesses aren't pushing for publicly funded health care here, since it would save them money in the end. I wonder if the effect employer-provided insurance has in discouraging people from leaving their jobs is part of it.

[silveradept]

That is definitely part of it. You can't trap people in terrible jobs that pay too little if they have good health coverage (and a good social safety net) when they're not employed. Capital needs exploitable workers to succeed, after all.