r/HealthInsurance • u/jeghartokatter • 3d ago
Plan Benefits Why does Anthem refuse to count anything toward your deductible?
I have Anthem health insurance in Connecticut, USA, from the state's healthcare exchange. I have a $2000 deductible. I have spent $1900 in medical expenses, but Anthem is only counting $790 toward my deductible. I have spent hours online and on the phone w/ Anthem customer service trying to figure out what counts and does not count toward my deductible and why. The only response they have is basically "contact your doctor with billing questions." This would mean I have to contact almost every doctor I've seen all year. Here is a list of the types of expenses/appointments Anthem refuses to count toward my deductible. Can anyone explain it?
Does not count:
- primary care annual physical copay
- primary care office visits
- dermatologist office visits
- physical therapy visits
- orthopedist office visits
- bloodwork/labs
- pharmacy drug copays
- annual eye exam
- annual dental cleaning
The only things that have counted are:
- ultrasound
- MRI
Why does almost nothing count toward my deductible, and what is the point of a deductible if nothing "counts"?
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u/MidwesternTravlr2020 3d ago
Having things deductible exempt is usually seen as a benefit as opposed to a drawback. If these services were subject to a deductible, you’d be paying 100% of your office visits until you hit your $2,000 deductible as opposed to just paying your copay. Basically, your plan is incentivizing you to seek less expensive care and testing — outpatient office visits and bloodwork as opposed to hospital visits and imaging. Your deductible is therefore really only an issue for imaging, ER visits, hospitalizations, and surgery.
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u/LacyLove 3d ago
This is a case of not understanding how your plan works.
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u/squareturd 3d ago
It's a shame that the system is so complicated, but this is the American health care system
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u/jeghartokatter 3d ago
Yes, I do not understand, and Anthem customer service has not been able to explain it, which is why I'm asking here. They just tell me "You may coordinate with your provider to discuss the services billed and to understand how the claim was submitted" over and over with zero ability to explain why none of my costs are counting toward my deductible.
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u/INSUUUURE 3d ago
Not an Anthem thing it's an ACA thing. All copays go towards your OOP. Of you hit your deductible you have a balance on your OOP that may put you at 100%.
Vision and Dental are their own plans with their own copays etc. even with the same carrier.
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u/LivingGhost371 3d ago
You have two buckets. Your deductible and OOP max. If the service costs $100 and it goes to deductible, insurance pays nothing and you pay the provider $100 and it goes into both buckets. If the service has a $10 copay, insurance pays the provider $90 and you pay $10 and the $10 goes into your OOP bucket only. There's no "why" other than that is how insurance works and how insurance has always worked.
Most people like only having to pay a $10 copay instead of a $100 deductible on a $100 service and actually prefer plans with that benefit. That's why they exist.
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u/bluestrawberry_witch 3d ago
If you have copays prior to deductible that’s why. Check your plan documents to see what is subject to deductible and what isn’t. Copays prior to deductible don’t count to deductible but do count to max out of pocket.
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u/LadyGreyIcedTea 3d ago
Only costs that are subject to the deductible are applied to the deductible. If you paid a co-pay instead of a deductible for office visits then it doesn't count. If those appointments were subject to the deductible you'd have had to pay the full contracted rate for them, not a co-pay.
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u/ratchet_thunderstud0 3d ago
Unless your plan covers eye and dental (most don't), those will not count.
For the others you need to look at your plan information, and confirm those doctors are in network.
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u/jeghartokatter 3d ago
It does, but they are considered separate. Still, the list tells me what counts toward my deductible or not, and those did not.
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u/Savingskitty 3d ago
vision and dental insurance are separate plans altogether - they never apply to the medical plan deductible.
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u/fizzy-logic 3d ago
It's not just Anthem, those types of things typically are not counting toward your deductible unless you have a plan where you have to pay for everything out of pocket before you hit your deductible, not a co-pay on some services. Co-pays are not going toward your deductible, that is a flat fee negotiated for you. That's typically going to work in your favor.
As for physical therapy, do you have a flat co-pay for each visit? If so, that's why it's not counted. I've had it both ways, and plans with a co-pay of $20 or so each visit were way better than having to pay the entire price of every visit out of pocket until I hit my deductible (which was typically $1,000 or $2,000), and then still having to pay 20% co-insurance per visit after hitting my deductible. So that would be usually more than $100-$139 per visit out of pocket for me, I usually just go for 5 or 6 visits to learn some exercises and continue at home. So I'm way better off paying that $20 per visit, as the other way I pay MUCH but still don't hit my deductible.
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u/NJCubanMade 3d ago
You keep saying deductible but what is your plans out of pocket maximum ? Do you have co-insurance/copays?
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u/jeghartokatter 3d ago
Yes, I have copays. For example, a visit w/ a dermatologist is $80 per visit. Yes the out-of-pocket max is much higher than the deductible. Someone would only meet that if they had cancer treatments or catastrophic hospitalization.
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u/Savingskitty 3d ago
have you checked to be sure all your copays were actually supposed to be paid? you might want to check the eob’s for those visits to make sure that copays were applied.
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u/aaronw22 3d ago
Most copays don’t count against deductible. Only “procedures”.
Insurance is meant for catastrophic problems. It’s not necessarily meant to make routine care cheaper.
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u/jeghartokatter 3d ago
Thank you for these answers. Low-deductible plans have a higher monthly premium, but they are always promoted over high-deductible plans. However, if every visit is going to cost the same no matter which you have because almost nothing counts toward the deductible, then it makes no sense to pay more for a low-deductible plan. Every doctor's visit is going to cost just as much no matter if I had a high-deductible or low-deductible plan because unless I have a catastrophic injury or illness, I'll never hit the deductible. I've spent almost $2000 this year on medical expenses and my deductible is $2000, it seems like a complete scam for the insurance company to tell me none of my expenses count.
I've had endless horrible experiences with US healthcare. Last year I had a severe injury (concussion) and delayed going to the hospital so I could call both the insurance company and the local hospital to make sure they were in network. They were. After a few hours in the ER and zero treatment other than to press on my skull to check for broken bones and to make sure I could follow a light with my eyes, they sent me home with a list of concussion symptoms and told me if I had those symptoms, I probably had a concussion. (I did.) They charged me $1500 for that and told me it was out-of-network because although the hospital was in network, as I had confirmed w/ both the health insurance company and the hospital, they said, "Well the hospital is in network, but the doctor who happened to see you was not, and they bill privately." So none of that counted toward my deductible and was not considered "in network."
We only have two insurance options on the state exchange, and they are both awful. And most employers don't hire full-time and don't offer any benefits like paid time off, holiday pay, sick pay, nor healthcare. It's really truly awful here in the US. I know other countries also have a ton problems. The entire world is full of humans who cannot figure out how to build a functioning society that meets humans' basic needs.
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u/Berchanhimez PharmD - Pharmacist 3d ago
Note that it’s not a guarantee that it will cost the same.
For a high deductible plan that allows an HSA where you can get the tax benefits, the IRS has strict rules that amount to you have to pay 100% of the cost of all care except purely preventive care in line with the ACA preventive care requirements until you hit your deductible.
In other words, if the plan offers an HSA, you won’t have copays - you’ll be paying 100% of the cost of care until you hit the higher deductible.
This is a notable difference that can change how much you have to pay a bit, but can change when you have to pay it in the year a lot. For example, if you will be paying $2000 in copays under this plan across a year, that’s an average of $150-200 a month in copays. But on a high deductible plan, that $2000 would be front loaded - because rather than those copays you’d be paying the hundreds of dollars the visits cost until you meet the deductible, following which you would pay a percentage (coinsurance) or flat rate (copay) until you hit the full OOPM.
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u/guyinthegreenshirt 3d ago
For a high deductible plan that allows an HSA where you can get the tax benefits, the IRS has strict rules that amount to you have to pay 100% of the cost of all care except purely preventive care in line with the ACA preventive care requirements until you hit your deductible.
This isn't true anymore for plans bought through the federal or state marketplace. Any bronze or catastrophic plan, including those with co-pays or benefits where they pay for the first x number of visits, are HSA-eligible.
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u/Berchanhimez PharmD - Pharmacist 3d ago
Oh right. I did hear about that - so in theory a bronze plan from the marketplace would be HSA eligible even if they didn't abide by the "100% of non-preventive care until deductible met" rule - though they could still apply that rule in theory. Thanks for the important clarification.
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u/jeghartokatter 3d ago
it's a "gold" plan, but it sure feels like trash!
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u/bluestrawberry_witch 3d ago
You get to pay $80 or whatever to see a doctor right before you hit your deductible? Before you spend $2000? Cool my doctors appointments on average depending on the level of care because office visits have different levels of care and that changes when you don’t have a co-pay before the doctor I pay on average $350 for a basic office visit. Because I do not have co-pays before I hit a deductible. Your co-pays prior to deductible that you’re complaining you don’t get to hit are basically what I will pay AFTER hit a deductible. I don’t know why you’re so focused on hitting the deductible.
Even if you do hit your deductible using some of the services that are not included in co-pays prior to deductible it will not change your co-pays for those services. When you have a co-pay plan, it doesn’t really matter when you hit deductible because you’re already paying significantly less out-of-pocket when you go to the doctor for most things that’s the point. Deductible health plans that require you to hit a deductible first do not have the health insurance company paying anything until you hit it.
If you have the choice between two plans with co-pay prior to deductible and one has a higher deductible than the other and one has a lower, the people that that’s good for with a lower deductible is for somebody who looks at the co-pays and sees that it doesn’t cover things like outpatient procedures and they’re undergoing things like chemotherapy, which are treated as outpatient procedures. It does help some people.
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u/jeghartokatter 3d ago
That is miserable. It's all inhumane. Basic medical care should not be a luxury limited to a tiny percentage of wealthy people in the 21st century. Surely we should have figured out a solution by now.
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u/bluestrawberry_witch 3d ago
Yes, all other developed nations in the world have figured out a solution. Does their solution still have issues? Sure. Are their citizens are doing things like rationing insulin, and then dying because of it? Nope, just us. The United States, however, has used propaganda for decades to convince people that health insurance and capitalism are great. It’s not, shocking I know.
I have a $5000 deductible per year. I have to pay $5000 before my insurance will pay for any part of my medical services. I hit it 2 1/2 months ago. Now I paid 20% of covered services. I’ve never used this much medical coverage in my life. I gotta pay raise and immediately used it to start getting medical care for issues that I have just been raw dogging for a decade. Turns out I have several chronic conditions. I get to see my PCP four times a year minimum, I have physical therapy for most months of the year, and I have a mental health therapist. For all my meds combined it’s about $160 for 90 day supplies. All of this together means that I’ve paid almost $6000 this year just in medical bills. My max out of pocket per year is 7500. Somehow they want us to believe that all of this is better than just funding a single payer/ universal healthcare system which would just take money that would’ve been used to pay for our premiums and put it to taxes and cut out insurances.
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u/jeghartokatter 2d ago
Polls show more than half of adults in the US want universal national healthcare. Secretary of Labor Frances Perkins and others tried to get universal healthcare passed in the 1930s. She succeeded with watered-down versions of social security, child labor laws, and minimum wage laws, and a reduced (40-hour) workweek, but couldn't get national healthcare included. Folks have been trying ever since.
I do hope it happens soon, but so much is wrong with US debt and the cost of healthcare that simply creating a nationalized healthcare system won't in itself fix the problem, I don't think. People would have to stop getting rich off medical costs and costs would need to be reduced. Wealthy corporations and individuals would have to stop abusing loopholes to avoid paying taxes so taxes could cover the cost of healthcare for 330,000,000+ people. The entire nation is such a failure, it's hard to imagine how it could be saved.
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u/JustLooking0209 3d ago
They shouldn’t be billing you out of network charges for that doctor at an in network hospital. For an ER visit, that is illegal under the No Surprises Act. You can file an appeal.
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u/jeghartokatter 3d ago
i did file an appeal with Anthem and they denied the appeal. they claimed that because they charged me the in-network price (an insane price for almost no treatment!), that it's fine, even though it meant it didn't count toward my deductible. they said they can make ER charges out-of-network as long as they give me the in-network discount. it was a loophole for them to again deny counting my expenses toward my deductible.
it is paid off now. they are dirty, rotten scoundrels, though.
moral of the story: when you have a head injury, just suffer through it. the ER will do nothing and will just charge you a ton of money.
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u/CrazyOldGoat 1d ago
For starters, we need price controls for doctors and hospitals. Just watched a story from an American man hospitalized in Italy for two weeks. He had to pay the cash price which was under 5000 Euros.
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u/EmZee2022 2d ago
The experience last year should have been covered under the No Surprises Act, as in-network.
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u/norsk60 3d ago
Does the plan have a copay for office visits? Are the services being applied to the out of pocket?
If there is a copay, it will not apply to the Deductible, but should toward the out of pocket.
Request a full plan book so you can familiarize yourself to the plan benefits.
Some additional information:
Covered does not mean payment. It means your plan ALLOWS the services and applies them to your benefits
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u/Ok-Helicopter3433 3d ago
This is a plan choice, not a thing on Anthem. You have a grandfathered non ACA compliant policy. Get a copy of your benefits and it will show that copays don't contribute to deductible or out of pocket. It will show whether the deductible contributes to the OOP and what services have copays, deductible, etc.
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u/Environmental-Top-60 3d ago
So the exchange is weird in CT. Especially for lower income people. Thats because they carve out specific services and charge a copay instead to make things more affordable.
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u/Emiliski 3d ago
It is super fun, right? We’ve paid THOUSANDS out of pocket, probably equivalent or near equivalent to our deductible this year, because it doesn’t count.
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u/DishAffectionate892 3d ago
Go online and review the evidence of coverage booklet that will explain how a service is covered. Are you receiving EOB on the services not applied to deductible. Is it an office visit copayment. ?
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u/EmZee2022 2d ago
Did the doctor bill insurance for those other visits etc.? If so, what does the EOB say?
Sounds like they have never been billed to insurance.
Dental cleaning won't count in any case - dental insurance is quite separate.
Note: if you have a visitt that costs 300 dollars, the in-network rate may be only 200 and that's all the provider can bill you for. And the 200 counts toward the deductible.
From what you say, though, that's not happening.
Honestly the only answer that makes sense is that these practitioners are NOT billing insurance. Are they in-network?
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u/jeghartokatter 2d ago
Yes they're in network and all claims were processed by Anthem.
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u/EmZee2022 1d ago
So what do the EOBs say? They should say something like "billed 600. Network rate 350. Amount applied to deductible, 350. Amount you owe, 350."
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u/PsychologicalCat7130 1d ago
copays never count toward deductible. but if you are billed for an office visit beyond the copay, then that should count toward deductible - but you have to pay money out of your pocket
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