Desperately seeking advice!

I’m trapped!  As some of you remember I have had an operation on one side of my brain (unilateral moyamoya); however, moyamoya has been developing on the other side of my brain in the last two years.   I am fortunate that my current employers insurance will cover the total cost if and when my second operation is needed.  The problem is, since it’s not full moyamoya, my doctor can not operate and there is no telling when I will actually need an operation.  I’m monitored every year.  

Here’s the problem, I have another skin disease (that is often related to moyamoya patients) called livedo reticularis; which is a skin disease that they only way to treat is living in a warm climate.  I’m an American currently living in Germany and would like to move to Los Angeles but am really nervous about the American health care system.  So, my question is…do insurance companies pay 100% of claims?  What has been your experience in having your operations covered under your insurance plans?  Any advise?

Thanks,
Monica

Hi Monica,

I'll attempt to answer your question however, US health insurance is complex. There are so many different variables in plan design, co-payments, deductibles and co-insurance.

The US doesn't have a universal healthcare system. It is one of private insurance.  To my knowledge, there is no health insurance in the US that pays 100% of claims. Even our federal health insurance program called Medicaid doesn't pay 100% of claims. They negotiate contracts with providers (hospitals and doctors) however, usually the patient under this program has no out-of-pocket expense or very little out-of-pocket expense.

Health insurance in the US can be very complicated to explain based on the many variables associated with different health plan designs, company policy in terms of healthcare payment of premiums and the associated co-pays, deductibles and co-insurance that typically are associated with health insurance.  There are some HMO's (Health Maintenance Organizations) that don't have deductibles but still have co-payments for office visits and there may be co-insurance and sometimes restrictions on the use of certain hospital and doctor networks.


Typically there are additional co-pays for prescription drugs.

Most insurance companies negotiate payment with providers (hospital and doctors and pharmacies).  Traditionally, there is a co-payment for some services, deductibles and co-insurance which are usually capped at a certain dollar amount.  This amount can be less for an individual and more for a family. The same for insurance premiums - less for an individual and more for a family.  Additionally, some companies pay only a portion of the actual insurance premium and the employee pays the remaining portion.  There are so many variables associated with the co-pays, deductibles and co-insurance based on the health plan design.  There is also in-network and out-of-network providers (hospitals and doctors) and depending on whether you are in-network or out-of-network you can pay more money out-of-pocket if out-of-network. This varies by insurance company and plan design.

Some small businesses don't offer insurance or if they do offer it, you must pay the entire premium.

As an example of what you may be faced with, I work for a very large employer. I pay a portion of my healthcare premiums, co-payments for both medical and drug coverage, deductibles and co-insurance.  My out-of-pocket expenses this year will be around $4,000 to $5,000. I have a traditional (PPO) family plan covering both me and my husband and I take only one precription medicine and my husband takes no prescription medicine. My dental and vision coverage is separate and I will have additional out-of-pocket expenses for those services.

I had a 3 day hospitalization a year ago (no surgery)and paid $2,000 out-of-pocket with deductible and co-insurance.

The US federal program called Medicaid is designed to be a "safety net" for people who have lost insurance coverage, or can't obtain insurance coverage. One must meet certain criteria to qualify for this program.

Due to the spiraling cost of healthcare in the US, many companies are moving toward a Consumer Driven healthcare plan that is typically a high deductible plan (minimum of $2,000 deductible but some have as high as a $5,000 or even $10,000 deductible) coupled with a Health Care Savings Account. This type of health plan requires a lot of employee education. It is designed to shift the cost of healthcare to the employee and away from the employer.

To address your concern regarding the US Healthcare System, traditionally, it has been considered the best healthcare system in the world both in terms of technical advances, healthcare quality and health outcomes. However, with global communication, curently, outcomes and price of healthcare that is delivered in the US is being challenged.  I believe we still have the best healthcare delivery system and especially with all the recent focus to change the quality and outcomes for the better.

I hope this helps to answer your question about current health insurance in the US.
 
Best regards,

Lore