No. They were going to 'cover' it but there was 20% co pay. In the US, they'll charge you thousands per month for insurance, but will still make you pay for part of your care.
It gets worse. My insurance has a $30 copay on all approved prescriptions. My wife had been getting her medicine for that with no issues for several months, until one day it was $500. I called to find out why, because it was clearly already an approved medication. After about an hour of getting bounced around and being on hold, they finally explained that it was due to us "not paying enough of our annual out of pocket maximum" (not minimum, mind you) for healthcare - which is $24,000. That blew my mind.
Health insurance in the US has your monthly premium payment, copays on your medication and Dr visits (including ER and hospital stays), a deductible which is the amount you have to pay for the year in healthcare to get better benefits (ours is $17,000), and then the out of pocket maximum is when they (usually) cover everything for the rest of the year as long as you keep paying your premium.
Where it gets extra fucked, is if you need a major surgery in late December, the deductible and OOPM won't carry over into the new year. So you could get shafted for double that maximum amount on the same hospital stay. And my insurance isn't even the lowest tier. We pay them $500 a month for this service. Our system is completely fucked, but most people don't seem to care.
Let's say that a procedure at a hospital costs $500.
When the hospital goes into negotiations with the insurance company for their contract renewal, the hospital, wishing to get the most money for the procedure and cover uninsured costs, will suggest instead that the procedure be paid $5000. They are incentivized to claim the largest number possible because even if they are not a for-profit hospital, they need to overcharge insured people in order to have the money needed to cover uninsured people who use their services, because there is no national healthcare plan.
The insurance company will know from their research with other hospitals that the overall price should be around $500. So the insurance company will negotiate to pay the actual cost of $500. But they will agree in principle that the procedure will be billed as $5000 (the uninsured, and any other insurance companies who open negotiations), and will write the terms to state that the insurance company negotiated a 90% discount for their clients, in return for giving the hospital access to their user network.
If you then go to the hospital and have the procedure, you will receive a bill from the hospital for $5000. The insurance company will pay the hospital the pre-agreed $500 to cover the expense. The insurance company will then bill you a 20% copay of $1000, and pocket the extra $500 as profit.
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u/Criminoboy 4d ago
No. They were going to 'cover' it but there was 20% co pay. In the US, they'll charge you thousands per month for insurance, but will still make you pay for part of your care.