SharonAndAdam.com

Health Insurance

Sometimes I think explaining the Holy Trinity is far easier than explaining how health insurance works.

Truly, I spent the greater part of the morning on the phone with Blue Cross Blue Shield of Texas trying to figure out what they mean by “maximum out-of-pocket” a.k.a. “co-insurance stop loss.”  It seems rather simple and indeed something that should be self-explanatory and work in favor of the insured.   The easy definition is as follows:

“Coinsurance is expressed as a percentage or pair of percentages generally with the insurer’s portion stated first. The maximum percentage the insured will be responsible for is generally no more than 50%. Coinsurance indicates how an insurer and an insured will share the costs of a bill that exceeds the insurance policy’s deductible up to the policy’s stop loss. Once the insured’s out-of-pocket expenses equal the stop loss the insurer will assume responsibility for 100% of any additional costs.”

What this nice definition fails to mention is that the out-of-pocket expenses are only considered up to the what the insurance company (in our case BCBS) accepts as an “allowable amount” for the medical expense.  If the insured on a PPO goes in-network for a medical procedure, the “allowable amount” for the procedure is agreed upon by the provider (e.g. the doctor) and the insurance company well in advance.  The insured meets the deductible, pays their portion of the co-insurance, and reaches the stop loss without paying unreasonable amounts of money.  HOWEVER, if the insured goes out-of-network (as we did for Adam’s surgery since the doc was the only one in a reasonable driving distance to do this procedure) all bets are off.  The provider can charge what s/he wants. The insurance company, at best, will only still pay the allowable amount for an in-network doctor which is in our case was only 1/5 of the actual cost of the procedure.  AND the deductible, co-insurance, and stop loss (if there is one) is ONLY applied to that “allowable amount,” not the total charges.   The insured can get “balance billed,” as we did, and pay the entire portion the insurance company does not pay.

At the end of the day it all really stinks. But it’s far better than socialized health care.

Two weeks down…

4 to go… of pureed soups for Adam.  His weight has leveled off and perhaps those extra ice creamy milk shakes are slowly adding back the pounds.

Thankfully we received more clarification on the procedure the surgeon is doing on Thursday.  Some of you may remember that Adam had jaw joint surgery about 6 years ago before we were married.  Dr. Nelson, the orthodontist,  said that wearing the rubber bands causes additional stress on the jaw joint and he wants to get Adam off the rubber bands as quickly as possible.  Adam’s two pairs of back teeth that still don’t touch need to be moved together more quickly.  In order to do that, one of the plates on his left side will be cut–not removed entirely.  This will allow those teeth to be pulled down in 3-4 months instead of 6.  The procedure should take less than an hour and Adam will be knocked out.  Dr. Nelson says it’s equivalent to having wisdom teeth remove.  Adam’s will not regress in his recovery but is still on course to continue the liquid diet for another 4 weeks before he can start on mushy food.  His goal–to have a piece of Gianna’s birthday cake!

Overall we’re starting to get back into the groove of life.  Despite what the blog reads, we haven’t totally be obsessing about Adam’s jaw.  The meals that people have brought certainly have helped and made meal time much easier.  Although, I can’t wait until Gianna is a year old and we can add in all those allergy related foods in her diet that are off limits now!!

Therese has been practicing her piano (on her own) and has mastered Bingo and Yankee Doodle.  Perhaps Adam can put up one of the videos or teach me to do it.  (hint hint sweetheart) Yesterday he picked up the next set of piano books.  We’re officially starting school next week and I’ve expanded our school area in what was once our breakfast nook.  I’ll be finishing up this week.  The kids and I are really excited.  Fulton has even expressed interest in learning to read.  (We’ll see if that happens…I won’t be pushing him.) Gianna’s a force to be reckoned with and wanting a part of big sister’s and big brother’s action–much to their dismay at times.  The cutest thing she says is “uh oh” when something falls.  She’s still not sleeping through the night, but sometimes I am! She made it from 8:30 p.m. to 6 a.m. today! That was a major breakthrough…and I and her roommate (Therese) just ignored the 4:30 a.m. episode.