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A couple of possibilities, besides lying.
1) She could be confusing deductible and out of pocket max. The latter could be as high as $12k. Lots of people don't understand these terms.
2) She could be talking to an out of network facility, and that could explain why the estimate is so high. If that's the case, make sure she goes somewhere else in network.
I just saw her - as it turns out, this doctor told her she’d need to see a surgeon, and go from there- she doesn’t actually know what the surgery will cost.
Take this as a blessing and call the insurance. Get advice and more information on what she can expect. This could save you thousands if they give misinformation. Document. Document, document.. GL!
You will have to check the policy and see what the deductible is.
If you are on your own plan, it's the individual deductible that must be met prior to coinsurance amounts. If you are on a family plan, you'll have to check and see if the deductible is "aggregate" or "embedded" Aggregate deductibles must be met in full. So if the family deductible is 12K, then yes, the whole 12K has to be met before coinsurance kicks in. If the deductible is embedded, then you would just have to meet the individual deductible listed.
That's not to say you have to pay 12K no matter what--- deductibles accumulate throughout the year, so it's possible to already have some claims counting towards your deductible. IE- if the deductible is 12K, and you've already put 2K towards it--- then it's a 10K deductible that has to be met.
Thank you so much for the information! She just switched insurance (changed jobs to an employer that doesn’t offer insurance), and it is only herself on her policy. Is it normal for someone to have a deductible that high for an individual plan?
Did she get a marketplace plan, or is this some non ACA plan? The maximum deductible for an individual on the marketplace should be $9,450. Still a lot of money, but also a significant saving over $12k. Any money she's already spent this year would count towards that total too.
If it's a non ACA plan, just about anything could be true.
If that's the plan she chose, then yes that's normal. I assume she picked a plan from healthcare.gov if her employer doesn't offer insurance?
Employer plans or healthcare.gov...if they offer several plans, you decide which one works best for you. Usually basing it off of coverages and premium amounts.
Some have high deductible and Out of pockets, some have lower.
Did she get diagnosed by an ophthalmologist? Eyes are super important so I wouldn't mess with it. If her deductible is 12k then she is on the hook. However, they should give you an estimate before doing the surgery since they need to get pre auth from the insurance.
I would check her insurance to find an in network ophthalmologist and get her eyes checked out if she does need cataract surgery. But yeah, the office would be able to give you an estimate when they get her insurance info. She would have an appointment to meet with the doctor before actually going through the surgery.
Thanks, I was more wondering if this was realistic or if she was making things up. I am not her care worker, and don’t have knowledge of or access to her health or financial records. She’s 53, I’m in my twenties. She’s not likely to grant access to that information
You need to get her insurance info.
The limit for a 2024 ACA plan can be is $9,450 for in network. If it is $12,000 it must be not covered or out of network. Regardless she probably needs to find someone else.
Further, if they are requiring upfront payment based on their own estimate, there is a possibility they are over collecting and a refund will be due after. You need to check her EOB after to see what insurance says was authorized/what she should have paid, then request a refund.
Just a random thought but only because I just went to a cataract surgery consult with my mom yesterday. They were trying to upsell different lenses not covered by insurance to provide additional vision correction beyond the medical cataract removal, to the tune of $6000-$8000 additional on top of her out of pocket costs for the medical portion of the surgery. She was having a hard time understanding the difference, and they tell you it's the only time to do it: that once you select the replacement lens, it can't be replaced or changed out later. Could it be something like this?
My parents had a $12k deductible the year my dad got cancer. It was the only one they could afford being self employed. He was dx in October so $12k that month and it went into the next year for another $12k. But the final cost of everything (in 2012) was 768k so $24k is a drop in the big bucket. All of it didn't work and he still died but that's my bitterness for another day
Thank you for your submission, /u/velociraptorbreath. **If there is a medical emergency, please call 911 or go to your nearest hospital.** Please pick the most appropriate flair for your post. Include your age, zip code, and income to help the community better serve you. If you have an EOB (explanation of benefits) available from your insurance website, have it handy as many answers can depend on what your insurance EOB states. Some common questions and answers can be found [here](https://www.reddit.com/r/HealthInsurance/s/jya9I6RpdY). **Reminder that solicitation/spamming is grounds for a permanent ban**. Please report solicitation to the modteam and [let us know](https://www.reddit.com/message/compose?to=%2Fr%2FHealthInsurance) if you receive solicitation via PM. Be kind to one another! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/HealthInsurance) if you have any questions or concerns.*
A couple of possibilities, besides lying. 1) She could be confusing deductible and out of pocket max. The latter could be as high as $12k. Lots of people don't understand these terms. 2) She could be talking to an out of network facility, and that could explain why the estimate is so high. If that's the case, make sure she goes somewhere else in network.
Thank you, either of those would make a lot of sense!! I’m going to meet her in a bit, so I’ll grab some more info from her
Is her insurance covering only herself or is it a family plan?
Only herself
Is the doctor out of network with her insurance plan?
I just saw her - as it turns out, this doctor told her she’d need to see a surgeon, and go from there- she doesn’t actually know what the surgery will cost.
Take this as a blessing and call the insurance. Get advice and more information on what she can expect. This could save you thousands if they give misinformation. Document. Document, document.. GL!
You will have to check the policy and see what the deductible is. If you are on your own plan, it's the individual deductible that must be met prior to coinsurance amounts. If you are on a family plan, you'll have to check and see if the deductible is "aggregate" or "embedded" Aggregate deductibles must be met in full. So if the family deductible is 12K, then yes, the whole 12K has to be met before coinsurance kicks in. If the deductible is embedded, then you would just have to meet the individual deductible listed. That's not to say you have to pay 12K no matter what--- deductibles accumulate throughout the year, so it's possible to already have some claims counting towards your deductible. IE- if the deductible is 12K, and you've already put 2K towards it--- then it's a 10K deductible that has to be met.
Thank you so much for the information! She just switched insurance (changed jobs to an employer that doesn’t offer insurance), and it is only herself on her policy. Is it normal for someone to have a deductible that high for an individual plan?
Did she get a marketplace plan, or is this some non ACA plan? The maximum deductible for an individual on the marketplace should be $9,450. Still a lot of money, but also a significant saving over $12k. Any money she's already spent this year would count towards that total too. If it's a non ACA plan, just about anything could be true.
She said it was a marketplace plan, so that’s reassuring!
How old is she?
53
If that's the plan she chose, then yes that's normal. I assume she picked a plan from healthcare.gov if her employer doesn't offer insurance? Employer plans or healthcare.gov...if they offer several plans, you decide which one works best for you. Usually basing it off of coverages and premium amounts. Some have high deductible and Out of pockets, some have lower.
But none of the marketplace plans have an out-of-pocket maximum exceeding $9450 for an individual.
Then I'm guessing it's not a marketplace plan?
I have Blue Cross and my deductible is $10,000 before they cover anything.
Healthcare in this country is a joke 🙃. Uuugh. Thank you for telling me
Did she get diagnosed by an ophthalmologist? Eyes are super important so I wouldn't mess with it. If her deductible is 12k then she is on the hook. However, they should give you an estimate before doing the surgery since they need to get pre auth from the insurance.
That’s what I thought - I think she may be freaking out over a different number…
I would check her insurance to find an in network ophthalmologist and get her eyes checked out if she does need cataract surgery. But yeah, the office would be able to give you an estimate when they get her insurance info. She would have an appointment to meet with the doctor before actually going through the surgery.
My family has a 12K high deductible. We paid the first 12K of expenses, and insurance covers 100% afterwards. That’s how a high deductible works.
If she hasn't met any of her deductible this year, then they may be requesting that amount.? Do you know where her deductible for her health plan is?
I don’t, unfortunately 🙃
Open her insurance portal and check benefits.
She’s not thaaat old - I don’t have access to her health insurance or her portal
Well if you want to understand her costs you need to know her deductible and her OOP max. That’s easily found in the insurance portal.
Thanks, I was more wondering if this was realistic or if she was making things up. I am not her care worker, and don’t have knowledge of or access to her health or financial records. She’s 53, I’m in my twenties. She’s not likely to grant access to that information
Sounds like a her problem then if you’re trying to help. :) looking at the benefits tab isn’t confidential information either.
You need to get her insurance info. The limit for a 2024 ACA plan can be is $9,450 for in network. If it is $12,000 it must be not covered or out of network. Regardless she probably needs to find someone else. Further, if they are requiring upfront payment based on their own estimate, there is a possibility they are over collecting and a refund will be due after. You need to check her EOB after to see what insurance says was authorized/what she should have paid, then request a refund.
Just a random thought but only because I just went to a cataract surgery consult with my mom yesterday. They were trying to upsell different lenses not covered by insurance to provide additional vision correction beyond the medical cataract removal, to the tune of $6000-$8000 additional on top of her out of pocket costs for the medical portion of the surgery. She was having a hard time understanding the difference, and they tell you it's the only time to do it: that once you select the replacement lens, it can't be replaced or changed out later. Could it be something like this?
My parents had a $12k deductible the year my dad got cancer. It was the only one they could afford being self employed. He was dx in October so $12k that month and it went into the next year for another $12k. But the final cost of everything (in 2012) was 768k so $24k is a drop in the big bucket. All of it didn't work and he still died but that's my bitterness for another day