Question about how insurance / payment works in the US

So first off, please know that in NO way do I want this to become a political post or for things to get 'hot'... but I have some questions about what our dear American friends have to go through in terms of financials when going through the WLS process. Mainly curiosity, but also because I am a little confused. (Canadian here, eh!)

So... if I am not mistaken... many of you have private insurance that you pay for... like, I am guessing a bill every month that you pay for this? Is this kind of like you would get a utility bill or a automobile insurance bill?

Do you get to choose what insurance provider you go with?

If so.... if there are insurance providers that seem to often say 'yes' to WLS, is it something that gets around, and people choose them, when the time comes to get insurance and WLS is something they are interested in?

So I understand that most people seem to be approved. But 'what is covered' seems to vary, is that right? Like sometimes only a % of the total cost is covered... or sometimes the procedure is covered, but not the meds, or the recovery room, or the various CT scans or tests before.

How about the pre- and post- care? Is that typically covered by insurance? Like, we have months / 1 year of classroom sessions, meetings with various specialists, scans, scopes, blood tests, workbooks and info binders and 3 weeks of Optifast before the actual procedure is done.

Also, after the procedure there are scans, appointments, tests, and follow up sessions and counseling available and all that kind of follow-up for 1-5 years available after (and longer if necessary).

Is all that typically covered by your private insurance? Or is that something typically that has to be paid out of pocket?

What happens if something goes wrong during the procedure? Is that covered as part of the insurance coverage?

What happens if there are complications after the procedure? Some issue develops? Is that covered as well? Is there a statute of limitations on the coverage? ie. Let's say 5 years after the procedure, there is a complication that has slowly developed with stricture. It's clearly to do with the original procedure... are you paying out of pocket for this?

Sorry for all the questions; I find it all very complicated and confusing and I've always wanted to understand how it works for you guys, and I figured this was a good place to ask :)

xo
A

Hi!

Insurance tends to be a paycheck deduction, so we (in the US) don't get a bill specifically for it, it's just taken out of our paychecks pre-tax.

Sometimes we have a choice? If insurance is accessed through employment (as it is for most of us) a company gets to decide which insurance companies it will use. Sometimes a company has multiple options, sometimes a company doesn't. If there are multiple options they tend to be with the same insurance provider but have different "tiers" or one might be a HMO option and the other a PPO option.

HMO - this is a managed care option where you don't get to pick your providers, need referrals for specialists, and your PCP is like the point of contact for everything else.

PPO - this is where you, normally, get to pick any provider participating with your insurance and don't need to use your PCP as a gatekeeper to other services.

(There are other models, and not all HMOs or PPOs are the same, these are just examples.)

Sadly, the insurance provider isn't the final word in what is/isn't allowed. Oftentimes the employer will put restrictions on services. For example, our last employer wouldn't cover anything related to weight loss even though the insurance provider certainly covers it for other employers. (It's confusing, eh?)

Some insurance companies have a co-pay that needs to be paid for services, this is a flat fee. For example, my tubal ligation cost $10. Woo! Some insurance companies have coinsurance, which tends to be a percentage. Then, when you reach your deductible for the year (i.e., when you've paid some amount of money out of pocket) you either don't have to pay copays/coinsurance, or your cost of those things will decrease, or whatever you've agreed to.

Pre- and post-op care coverage depends on the insurance company. For me, those things are "covered," but I still have to pay copays for visits and lab work. For some people, they're not covered. And, of course, it's not uncommon to change insurance either due to change in employment or change in what the employer offers. "Yay."

If surgery is covered, complications during surgery are covered. Ditto for complications after surgery. However, again, if you lose insurance, you might be screwed. You're only covered for stuff while you have the insurance you've got. New insurance might have different coverage.

It's pretty ****ty. I was just doing research for a class and, in Norway for example, they pay 40% (approx) in payroll taxes and have a 25% VAT, but get WAY more than we do in the US for that tax money. My family pays 38% in payroll taxes/deductions, variable sales tax, and gets inadequate retirement funds, no education, and health insurance that we still need to pay extra for. Awesome, eh?

My health insurance is employer based. So my employer pays X amount of the premium, and I pay a small fraction of the cost through my pay. (IE $1500 the employer pays, I pay ~$80/month.) I work for municipal government so rate are typical cheaper since it a large employer. My employer offered two insurers, I got to pick which one I wanted.

The employer determines the type of policy and whats covered. They also determine what the out of pocket costs are; co-pays, deductibles. etc. As long as I'm referred to a specialist, anything (tests, etc- within reason) that the specialist orders is covered. Referrals are only good for 90 days, so they must be renewed- I've never had a problem getting it renewed.

Any complications from my WLS are covered, but as time goes on I imagine they may not connect issues to my surgery at all, they may just be 'new issues'.

My surgery cost be maybe $250 out of pocket.

there are soooo many available insurance packages out there and they all vary so much, and most people are kind of stuck with accepting the insurance package their employer chooses to go with, because they get a significant discount off of their premium payments for a better plan instead of choosing a private insurance plan on their own and paying more out of pocket for less coverage. plans through employers are generally subtracted from your income automatically, and private insurance plans are paid monthly, like a utility bill or auto insurance, etc.

some packages have more exclusions than others, and some will require more prior authorizations and proofs of medical necessity than others, but they are all dependent on the individual plan provisions.

obviously, the plans and packages with the best benefits, highest levels of coverage and lowest Out of pocket/deductible plans are going to be the plans with the highest premiums.
I am lucky because my husband works for a very large international bank and they have pretty good insurance benefits for their employers. We do pay a higher premium amount for a lower deductible plan, and it ends up being somewhere around $300/month to cover my husband, myself and our daughter.

example:

we have a $1000/year deductible per family member that needs to be met before the insurance will pay 80% of eligible expenses for the year, or a combined $2700 family deductible... although some things are covered at 100%, like preventive care exams (colonoscopy, mammogram, pap smear, prostate exam, etc), yearly wellness/ physical exams, yearly lab work, etc.
other things due to accident/injury/illness would be subject to the deductible. then we have another yearly Out of pocket or co-insurance max, which is an additional $1000 per member per calendar year (this deductible/OOP starts over every January 1st)...so once our insurance is paying 80% and we are responsible for 20% of expenses, once that 20% adds up to $1000, the insurance will cover 100% for the rest of the year. so basically once I have paid up to $2000 out of my own pocket for any medical expenses for the year, my insurance will pay everything else 100%.

some plans do have yearly and lifetime maximums though...some are like $100,000, some are 1 million, some are 9 million, and some have no maximum.

some plans have co-payments for different services (the insurance pays a negotiated/contracted amount to the facility or doctor and you are responsible for a set amount like $35 for a specialist, $100 for the Emergency room, $150 for an MRI, etc)

generally speaking, if your insurance plan covers a procedure, they will cover your follow ups and other complications relating to your procedure...but again, once the year begins again, you will need to fork over your deductible all over again before they start paying.

I work in the insurance authorizations department in a medical office and I can tell you it is very rare to see a deductible less than $500 anymore, and almost unheard of to see a plan with no deductible. If I had to pay for insurance through my employer instead of my husband, the plan would cost us over $800 a month to cover my family, and our Deductible would be $5,000 per person and $10,000 for the family.

Oh, wow! It's all very complex and I don't think I really realized that it could be very different scenarios for different people. Thank you SO much for the explanations!!

I have so many more questions, hahaha, but I will use what you gave me and do a bit more research!

Thank you for all the details!

For those of us who are self pay, it all varies state by state and then region by region. Someone in rural colorado will have completely different insurance availability and coverage than someone like me, who lives in the Denver area.

Those of us who live in predominantly blue states have greater medicaid (Govt paid) coverage than those governed by red state - that is where politics inserts itself into healthcare. . My 14 year old son, for example, has his healthcare covered 100%, together with waivers for help with his lifelong disability. If I lived in other states, we would be on own own for therapies, respite care etc. Those waivers are worth $10-35k per year.

I pay my own, $620 ish per month, and I have a $5500 deductible and 30% co pays. This is why medical bankruptcy is so common here. I'm fine while I'm healthy, but could lose everything if I got, say, cancer or ALS.

Every insurance policy is different. Some cover everything. Some cover nothing when it comes to WLS. We are covered through my husband's work. We are offered a choice of 5-7 plans each year with varying deductibles and co-pays (and, of course, premiums). The premium is deducted from his paycheck for the plan we choose. We pay about $600 a month for coverage for 4 of us (that's just the premium without the co-pays.)

We have a PPO that is very good - we have no deductible if we stay in network and the network of phyisicans is very good. When I had my surgery, I paid office visit co-pays of $40 per visit to the surgeon and other specialists, had a co-pay of about $75 for lab work that was done and the endoscopy. My surgery cost me $700, because that was my share of the hospital for one night.

Here's the good news, my abdominoplasty is 100% covered with a $500 overnight hospital deductible, my breast lift will be covered the same way and there is a very good chance my brachioplasty (arms) will be covered. Even if the arms aren't covered, my plastics guy has offered to pair them with the abdominoplasty and my add-on cost would be $4k out of pocket, which is somewhat do-able.

But we are very lucky to have very good insurance. Many people I know have policies that do not provide coverage for WLS at all.

I just can't understand health insurance basics I know it's important but it's just too complicated to understand

are you an American living in the United States?

I'm an American currently working overseas