For
over two decades we had been on a health maintenance organization
(HMO) insurance plan. Like most people, we believed that it was
the best. It began with just $5.00 co-pay fees for office
visits when we were sick and "free" child well-visit
appointments. Both of my pregnancies medical needs were fully paid
for. And if we had to go to the ER, it was covered 100%. My
husband's employer paid the largest part of the premium, while a
reasonable amount was taken out of my husband's pay for the
rest.
Then things began to change. Those $5.00
co-pay fees went up to $20.00 for a family doctor and
$40.00 for a specialist. And not only did ER visits start
charging a $50.00 co-pay, but doctors began
to discourage patients from going to ER; or in my case,
out and out lie so that I would not go. --I did end up there,
but a bit after the fact and with a gangrenous-ruptured
appendix. And the cost for this plan went way beyond
reasonable.
That lie by my old doctor, I believe was due in
part to insurance company kickbacks. Doctors, who do not send many
HMO patients to the ER, get more than a pat on the
back from insurance companies. Don't ever think that your
insurance company works for you, because it does not. Insurance
companies work for doctors, which should be illegal. But is
not.
HMO insurance policies put our total care into the hands
of a health insurance company and the doctors. They set the
prices, all around. They say what procedures can and cannot be done.
They even say what type of doctors we can see, for any given
situation. Handing over this much power to two entities that are in
bed with each other is absurd.
As
a result, it is not always our best interest that a doctor has in
mind, but rather his or hers. There is another option.
That
option is to get out of the HMO policy and back in control of our
own health care. And, at this time, a great way to do that is with a
high deductible health insurance plan. Let me tell you how ours
works, compared to an HMO. It is very much like the old days, when
the major part of what was covered by a health insurance company,
was "Major Medical." Only it is even better.
We have been on
a high deductible plan for close to two years. But I will use
the newest figures from what the plan will be renewed at, this
March. I will also use the newest figures for the HMO plan
that we could have chosen, if we wanted an HMO.
Let's begin
with the cost of the HMO plan, which is still largely paid for by
the employer. If we were to choose the HMO, it would cost $125.00 a
week out of my husband's paycheck, for 50 weeks. That would
be $6,250.00 for the year. And that is on top of the
thousands of dollars that are paid by the employer. --And if we
do not use $6,250.00 worth of care, we get none of it
back.
Now, let's compare that to the high deductable that we
choose to be on. The employer still pays the same amount that he
would have paid, if we were on an HMO and we pay less than $15.00 a
week, for 50 weeks (roughly $750.00). But now we have a high
deductable, which for our family plan is $3,600.00 a year, with an
out-of-pocket maximum of $7,200.00. If and when we reach the
$3,600.00, we go on what is called co-insurance, until we reach the
out-of-pocket maxium. The co-insurance cost to us would be
10% of whatever the cost is, and the insurance company pays the
90%.
It works like this, if we need a prescription or a
doctor's visit or an ER visit or surgery or even just blood
work done, we pay until we reach the high deductible of $3,600.00.
After that, we only pay 10% of the cost, but only until we reach the
out-of-pocket maximum of $7,200.00 (this is with the exception of
prescriptions, which we would then pay a co-pay that is very much
like what is paid on HMO policies at all times.)
Once we
were to reach the $7,200.00 out of pocket maximum, everything is
covered in full, even prescription drugs.
Now there is
something that my husband's work is doing that might not be done by
all employers, but clearly would be done by many, considering that
it can be done. My husband's work would pick up the 10% that we
would have to pay, between the $3,600.00 and the $7,200.00, with the
exception of prescription drug co-pays. This means that outside of
possible prescription co-pays, after the high deductible would be
met, we are only risking paying $3,600.00 a year, above the
roughly $750.00 a year. This is as oppose to paying $6,250.00 a year
for an HMO. And again, once the $7,200.00 out-of-pocket is met,
between the original $3,600.00, the 10% paid for by the employer,
and any prescription drug co-pays, then everything will be covered
in full by the insurance company. That is even on prescription
drugs. And there would be no co-pays or co-insurance at that point,
either.
Also, because we are on a high deductible policy, we
are able to have a health savings account (HSA). An HSA is a fully
tax-exempt bank account. And by "fully tax-exempt," I mean that
there are no state or federal or Social Security
taxes taken out of the pay that goes into an HSA account. We
can put up to $6,250.00 for the year, into our HSA; and any money
that remains at the end of the year, rolls over to the next year and
another $6,250.00 can be added to it the next year. This money can
also be used for dental and eyewear costs, which often are not
included in regular health insurance policies. --Though dental and
eyewear costs cannot go towards reaching the deductible and
out-of-pocket amounts, it is great to not pay any income taxes or
Social Security tax on money used for these things. And because
we can roll over money to the next year, we could really save up a
lot of money for health care needs, over the years to come. And that
tax-free money could very much come in handy some
day.
Another
thing to keep in mind is that with most HMO plans there is no
out-of-pocket maximum. This means that those $20.00 and $40.00
doctor co-pays, $50 ER co-pays and all prescription co-pays, have no
maximum cost. If we were on an HMO, paying out $125.00 a week for 50
weeks ($6,250.00 for the year), we would still pay those co-pays.
And none of those co-pays are tax-exempt. Well, that is
unless we wanted to gamble with our money and put some into a
flex-spending account, which we would lose any that did not get used
in the year. What!!! I don't think so!
And one more tidbit
about our high deductible plan: Some preventive care is fully
covered, from the get-go. Those things are, yearly doctor's
office physicals, yearly GYN appointments, colonoscopies,
prostate screanings, and even mammograms. Well child visits would
also be covered in full, if we still had young children.
In
our case the high deductible is the better way. But this is not
just with monetary costs. This puts us in charge of what is going
on. Not only am I not left out of the loop, as to what things cost
and can choose the best for my money; I now know that there are
no kickbacks going to doctors that would encourage them to talk
me out of going to the ER or to any other medical place. I do
not need a doctor's approval to do something. I am now in charge of
my care. And I like it this
way.
