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Old 07-03-2008, 01:28 PM
5 posts, read 33,276 times
Reputation: 10


Hi all,

My husband recently got a job offer in Austin. Because we are from Canada and healthcare is different here, we are unsure whether the health benefits offered by this Austin company are reasonable or not.

From what I can remember, the company will pay 100% of his expenses and 50% of his dependents (me and our two children). So he has to pay this missing 50% out of his paycheque so that all of us will be completely covered under the plan. There is a distinction between "network" doctors and out-of-network doctors, and if we go with a out-of-network doctor, we will have to pay more. There is a small copayment required for most if not all services. For some services the plan will start paying a percentage only after we have paid a base amount. There are drug benefits but not any vision care, chiropractic, etc.

Does this sound reasonable? Good? Bad? Do most people get visioncare and chiropractic included in their benefits? What is a "network " doctor? Are these the ones who are not as good or who pass you around from doctor to doctor so you don't see the same one everytime? Is it much better to get a non-network doctor instead?

Also, what is an HMO? How is this different from a network doctor?

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Old 07-03-2008, 02:42 PM
Location: Austin 'burbs
3,225 posts, read 13,620,151 times
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the company will pay 100% of his expenses and 50% of his dependents (me and our two children).
What you mean is, the company will pay for his premiums - so he essentially has "free" or paid healthcare (it's not really free, will get to that in a minute) and they will pay 50% of the premiums for the family. The premiums are basically the cost to purchase a health care plan.

Then, as you can see from more of the details in the plan, there is still some out of pocket money, above and beyond just the purchase of the plan.

"Network" doctors are just those who are part of an insurance plan, and does not guarantee quality, but nor is it a determination for doctors that aren't as good. Most doctors will be part of the network for the major insurance carriers in a given area. In this area, I think some of the bigger name health plans are Humana, Blue Cross, Blue Shield, Scott & white ... and I can't think of the other one I have heard... If your plan is with one of the more well known insurance companies, you won't likely have to go out of plan. Usually, the only case where the "out of plan" thing comes in handy, in my experience, is if you are particularly set on keeping the same doctor you have had forever.

A copayment is normal - anywhere from $0-20 for a regular doctor, to perhaps $40 for a specialist.

All the plans I have ever had included vision, or at least had it for additional purchase ... are you sure you can't purchase that in addition to the main health plan?

Everyone will tell you "you don't want an HMO" but I think HMO's are slightly different than they used to be. If you have an another option, I would elect that over an HMO - but that's because we, personally, see lots of specialists. If you have just regular well child checks, and annual exams for yourself and your husband - an HMO would probably be fine, and it's less expensive.
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Old 07-03-2008, 02:48 PM
56 posts, read 259,820 times
Reputation: 36
What you are describing sounds like a PPO (Preferred Provider Organization) plan. The base amount that you have to pay is called a deductible and the percentage that you pay after you meet your deductible is called "share of cost". A "good" plan will have low premiums (the amount taken from your husband's paycheck), a low deductible and no more than 20% share of cost. It is also nice if your plan has a copay-only option for using in-network doctors. That means that you can visit these doctors for a set fee, say $25, and you don't have to meet your deductible. Not all plans have this option. An "in-network" physician only means that they have a contract with your insurance carrier. The quality of the doctor is irrelevant. Non-network doctors just don't have a contract. It would be in your best interest to use in-network physicians. At times, though, that may not be possible (like in an emergency), so at least you have some coverage rather than being 100% responsible. Generally using a non-network physician will only be covered at 50%. Remember that you have to meet your deductible before the plan starts to cover their share (most often 80 or 90%). With this type of plan, you are free to see any doctor you choose, when you choose. You do not need any referrals from a primary care physician. You have a skin problem, you make an appointment with a dermatologist straight away.

An HMO is a Health maintenance Organization. Generally with this type of plan, you will only be responsible for office visit copays. However, you don't have the option to use a non-network physician and all of your care needs to be directed by your primary care physician. meaning, if you have a problem with your skin, you will need to see your PCP first then if he or she cannot treat your problem, you will be referred to a dermatologist (that's just an example, many plans have a few specialists to which you may self-refer without seeing your PCP. GYN is a common self referral).

In my experience, the coverage offered in Austin is pricey. You really have to pay for great coverage.
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Old 07-04-2008, 04:24 PM
351 posts, read 309,187 times
Reputation: 60
The benefits you described are very typical here in the US. They sound very reasonable and in my experience with two small children I would not do an HMO two much wait time to be referred by your primary Dr. What you need to do is get referral's for Dr./dentist and then find out if they take your insurance so that you will be "in-network" meaning they have a contracted fee schedule with your insurance and will pay the bill after you pay your co-pay. Good Luck to you.
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