Knowing your Cost for Insurance is More than the Premium

Recently I presented a renewal to a client who at my suggestion wanted to look at alternate plan designs.  This client has the Kaiser $50 co-pay in place currently.  I always suggest looking at what else is out there just to make sure you’re aware of the options and current pricing.

As an insurance broker, I know when you compare the $50 Kaiser co-pay plan to other carriers with comparable benefits, Kaiser rates always wins.  But it’s good to see it for yourself.

One of the best “priced” plans in today’s world is offered by Aetna.  The premiums are reasonable (in an insurance kind of way) but the plan design comes with a $10,000 deductible.

The deductible is waived for office visits, the first $300 of diagnostic lab and x-ray, and prescription drugs.  Preventive care is covered at 100% without the deductible coming into play too, but that’s due to PPACA (Patient Protection and Affordable Care Act.

Once the deductible of $10,000  is met, the coverage kicks in at 100% for covered in-network charges and 50% for covered out-of-network charges.  My client told me his employees would look at that plan as having no coverage at all.  I know how such a large deductible can frighten even the toughest people.  That “what if” factor is very scary.

I CAN’T BELIEVE IT HAPPENED TO ME!

I recently had an experience where I had to visit the emergency room.  This was my first time in the ER and here’s how it happened.  I have a soft spot in my heart for animals.  There’s a feral cat that hangs out at my office that I’ve been feeding  for awhile.  I named him Tuxie (he’s a tuxedo cat so why not!).  A little more than a week ago I noticed he was limping severely and had a gouge by his eye.  So I borrowed a trap and off he went to my veterinarian, Dr. Virk, who fixed him up, and neutered him.  He suggested I keep him contained for a few days while his paw was healing.

At one point Tuxie got out of his cage and I knew I would have to trap him again to get him back in the cage.  The cat was too smart for me.  I tried sardines, and tuna but he was not going back in that trap.  My husband and I tried to chase him down in the garage and Tuxie bit my husband.  Finally I covered the trap with a blanket and the cat couldn’t resist the canned food.  My husband and I finally had him.  We decided to transfer him from the trap to the cage. The cage is much bigger than the trap and he would be more comfortable there.   We planned it out and we were prepared.  But again he outwitted us.  As we were slipping him in the cage, he escaped.  I reached out to grab him (what was I thinking?)  and he bit me.  (Don’t be mad at Tuxie, he was just defending himself)  There were seven holes in my finger which swelled and turned red.  The rest of my hand soon followed the injured finger.  Who knew a cat bite could be that bad?  At this point,  my husband insisted on going to the Emergency Room.

HOW MUCH DO I HAVE TO PAY?

My emergency room experience was very good. As I sat with the antibiotic drip going into my arm I thought about the cost of the emergency room.  There are no bills at the time of service.  You just go if you need to and fork over  the co-pay.  But what if I had that Aetna $10,000 deductible plan?  What if the bill was $4000?  I would be paying that $4000 out of my own pocket? YIKES!!

I think most people would have a hard time coming up with that kind of money (that’s roughly 20 pairs of Jimmy Choo shoes by the way!).  Don’t get me wrong, I’m not criticizing Aetna for coming up with such a plan design.  It certainly is an option for employers that may not be in a position to pay for a more expensive plan and of course it’s better than not having insurance altogether.  It is in fact a catastrophic plan with a few important things covered as first dollar benefits.

So let’s say I did have that plan with the $10,000 deductible.  I would have done as much as I could to avoid the emergency room.  I would have probably called my veterinarian, Dr. Virk, and asked him for his advice.  I would have waited a day and called my doctor for an appointment.  But let’s say you have an emergency that can’t wait.  You aren’t going to call your veterinarian for advice if you’re having chest pains, and that’s probably not something you want to wait on for treatment.

ADVICE FROM YOUR FAVORITE BROKER

So what’s my advice you’re probably asking yourself.  You need to weigh all the issues.  You never expect to go to the emergency room.  Heck I made it 50 years before I needed to go the ER.  I think it’s always best to look at your maximum exposure as far as out of pocket expense go.  Can you afford that much if something happens to you?  Choose wisely, Grasshopper!

P.S.  Tuxie is doing fine and back in his original community with his best friend BBK (Big Black Kitty)