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Thread: Insurance coverage and out of pockets?

  1. #1
    Join Date
    Oct 2008
    Location
    Sunshine Coast, Queensland, Australia
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    3,133

    Insurance coverage and out of pockets?

    The discussions regarding insurance are interesting. Just wondering how much this surgery cost your health insurance fund and how much came out of your own pocket?

    I am in a hospital only fund, which costs <$80 per month. The Australian Government pays 30% of Health Fund premiums, the $80 is the net amount. This means my hospital stays and surgery are covered. But radiography, pharmacy, physio etc. are not covered. For approx double the premium, those items would be covered, along with optical, chiro and various other treatments. I am not covered for those items because I rarely use them, so if I need them, they are out of pocket.

    My fund paid out $105,000 for my surgery. My out of pockets including the above items not covered, plus appts with Dr. Askin amounted to around $7,500. Worth every cent.

    Now, the Medicare system in Australia means I could have had my surgery for nothing. But I would have been placed on a long waiting list for non-urgent cases and I would not have been able to choose my surgeon.
    Surgery March 3, 2009 at almost 58, now 63.
    Dr. Askin, Brisbane, Australia
    T4-Pelvis, Posterior only
    Osteotomies and Laminectomies
    Was 68 degrees, now 22 and pain free

  2. #2
    Join Date
    May 2009
    Posts
    3,594
    I(early) retired almost 3 years ago due to pain..i pay $300 a month (& $300 a month for my husband) for my coverage...it is pretty good, but i can only go to in network doctors...Dr. Anand in CA doesnt take my insurance, cause it is an HMO...not the better version of PPO...which is waaay more expensive per month...i also have medicare for the past 6 months, but alot of good doctors also dont take that...this is the state of how health insurance is in America...before i retired, i had the same insurance but paid alot less per month for it.....

    i have several doctors i see who take no insurance...i just pay them cash...it gets really expensive...it is one thing to see them one time for a consult, like dr boachie, but the one i see several times every year runs into money!

    dont know if it will get much better with the changes the President is trying for...i think it will get better for those with no insurance....those of us with insurance...dont think it will matter....

    jess

  3. #3
    Join Date
    Oct 2008
    Location
    Sunshine Coast, Queensland, Australia
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    3,133
    Hi Jess. What does HMO and PPO stand for? And what exactly is "in network"?

    Here, to the best of my knowledge, specialists accept any insurance fund, which are all bound to pay the bill.
    Surgery March 3, 2009 at almost 58, now 63.
    Dr. Askin, Brisbane, Australia
    T4-Pelvis, Posterior only
    Osteotomies and Laminectomies
    Was 68 degrees, now 22 and pain free

  4. #4
    Join Date
    May 2009
    Posts
    3,594
    Hi Jen
    HMO is a group...it is the cheaper choice...it allows you only to see doctors on the list of the insurance company..those doctors accept your insurance...PPO is more expensive..it pays for doctors of your choosing outside of the "network"...outside of the approved list...it can cost more than double the HMO cost that the patient pays monthly.......it gives you freedom of choice...

    in America, doctors accept some insurance companies & not others....some insurance companies are known for having better doctors on their list...other insurance companies will pay a percentage of the cost of a doctor out of network...for example, GHI ......you can go to a GHI doctor & be 100% covered, or go to an out of GHI doctor & GHI will send you maybe 25% reimbursement of what you paid out...

    hope that explains it...

    jess

  5. #5
    Join Date
    Oct 2008
    Location
    Sunshine Coast, Queensland, Australia
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    3,133
    Thanks Jess, that does explain it.
    Surgery March 3, 2009 at almost 58, now 63.
    Dr. Askin, Brisbane, Australia
    T4-Pelvis, Posterior only
    Osteotomies and Laminectomies
    Was 68 degrees, now 22 and pain free

  6. #6
    Join Date
    May 2008
    Location
    Central NJ
    Posts
    1,955
    Quote Originally Posted by jrnyc View Post
    I(early) retired almost 3 years ago due to pain..i pay $300 a month (& $300 a month for my husband) for my coverage...it is pretty good, but i can only go to in network doctors...Dr. Anand in CA doesnt take my insurance, cause it is an HMO...not the better version of PPO...which is waaay more expensive per month...i also have medicare for the past 6 months, but alot of good doctors also dont take that...this is the state of how health insurance is in America...before i retired, i had the same insurance but paid alot less per month for it.....

    i have several doctors i see who take no insurance...i just pay them cash...it gets really expensive...it is one thing to see them one time for a consult, like dr boachie, but the one i see several times every year runs into money!

    dont know if it will get much better with the changes the President is trying for...i think it will get better for those with no insurance....those of us with insurance...dont think it will matter....

    jess
    What is your network Jess? I can't remember, is it Aetna?
    __________________________________________
    Debbe - 50 yrs old

    Milwalkee Brace 1976 - 79
    Told by Dr. my curve would never progress

    Surgery 10/15/08 in NYC by Dr. Michael Neuwirth
    Pre-Surgury Thorasic: 66 degrees
    Pre-Surgery Lumbar: 66 degrees

    Post-Surgery Thorasic: 34 degrees
    Post-Surgery Lumbar: 22 degrees

  7. #7
    Join Date
    May 2009
    Posts
    3,594
    Hey Deb
    yup, Aetna HMO...cant really afford the better PPO!

    paid alot of people out of pocklet who dont take insurance or dont take mine...dr anand, dr boachie, my hormone doctor in santa monica, etc...adds up!! i am sure there will still be doctors who dont take insurance even after this country passes some kinda health care bill!

    jess

  8. #8
    Join Date
    May 2008
    Location
    Central NJ
    Posts
    1,955
    Quote Originally Posted by jrnyc View Post
    Hey Deb
    yup, Aetna HMO...cant really afford the better PPO!

    paid alot of people out of pocklet who dont take insurance or dont take mine...dr anand, dr boachie, my hormone doctor in santa monica, etc...adds up!! i am sure there will still be doctors who dont take insurance even after this country passes some kinda health care bill!

    jess
    Im the same Jess, my husband has his own small business and we got thru that. Family coverage is $1300/month without dental. My husband does computer work for a dentist and they barter their services. I always said I'd never go with a straight HMO, but it was $300 more per month for a PPO.

    However. I do have to say that in my area at least, I prefer Aetna's network much better than some other insurance companies.
    __________________________________________
    Debbe - 50 yrs old

    Milwalkee Brace 1976 - 79
    Told by Dr. my curve would never progress

    Surgery 10/15/08 in NYC by Dr. Michael Neuwirth
    Pre-Surgury Thorasic: 66 degrees
    Pre-Surgery Lumbar: 66 degrees

    Post-Surgery Thorasic: 34 degrees
    Post-Surgery Lumbar: 22 degrees

  9. #9
    Join Date
    May 2009
    Posts
    3,594
    i know how it is, Deb...you spend double what i do!!! i spend over $650 a month on myself & my husband (no dental)...it would be much less if i were still working! i used to have GHI..their doctors were awful, though they did reimburse for out of network...but very very little! then i switched to Cigna, cause my GP started taking it...then Aetna, cause GP stopped taking Cigna, & he only took Oxford...we couldnt get Oxford (teachers union in NYC)...now he takes my Medicare, which i think is pretty funny...but none of my other doctors take Medicare...i am thinking of dropping it! i pay $100 a month for it...& will not drop Aetna, so i dont know if Medicare is even worth it!
    and the Medicare/Aetna combination...must not be great, as none of my doctors take that! my Aetna covers hospitals, docotrs in network, labs, x rays, etc.

    i like most of the doctors who take Aetna HMO, so it is OK...Dr Anand takes Aetna PPO, i think...he doesnt take Aetna HMO, that 's for sure! $560 to see him for a consult!

    sometimes i worry that doctors who take my Aetna will stop taking it! maybe i better hurry up with my surgery decision!!

    jess

  10. #10
    Join Date
    Aug 2008
    Location
    Indianapolis, IN
    Posts
    416

    Wink Insurance Coverage

    I was very very very fortunate to have a good policy through my employer. I had Anthem Blue Cross/Blue Shield with 100% coverage. I only had a $500 deductible for the hospital and the insurance co. paid out almost $200,000 for my hospitalization. Wow...
    May 2008 Fusion T4 - S1, Pre-op Curves T45, L70 (age 48). Unsuccessful surgery.

    March 18, 2010 (age 50). Revision with L3 Osteotomy, Replacement of hardware T11 - S1 , addition of bilateral pelvic fixation. Correction of sagittal imbalance and kyphosis.

    January 24, 2012 (age 52) Revision to repair pseudoarthrosis and 2 broken rods at L3/L4.

  11. #11
    Join Date
    May 2009
    Location
    Adelaide, Australia
    Posts
    424
    I pay $1096.00 per quarter on a Family cover plan. This is a top table cover and covers everything medical and dental. My total surgery bill was $67,000.00. This included 8 days in a private room, physio everyday, theatre fees, surgeon, assistant surgeon and anaethetist fees, hardware costs, in hospital xrays and pain meds on discharge. My total out of pockets came to $450.00. Worth every penny i thought.
    Vali
    44 years young! now 45
    Surgery - June 1st, 2009
    Dr David Hall - Adelaide Spine Clinic
    St. Andrews Hospital, Adelaide, South Australia
    Pre-op curve - 58 degree lumbar
    Post -op - 5 degrees
    T11 - S1 Posterior
    L4/5 - L5/S1 Anterior Fusion

  12. #12
    Join Date
    Nov 2010
    Location
    British Columbia
    Posts
    929
    We all have free medical coverage here in Canada so the surgery for my son (if needed) won't cost us anything BUT there is a grand total of two surgeons in the entire province of BC who work with kids' scoliosis so the wait list is LONG. For that reason I am looking into Shriners BUT have been told that if we go that route there will be no followups provided by the Children's hospital in Vancouver. I am not sure what to do just yet but am definitely looking into things.

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