wth is a copay

Angst

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so i decided before making pasta to see a bdg video. watching it gave me an absolute headache of a void, which i'll only be able to cover with some distracting cartoons & the delicious pasta imma make in a moment.

let's go (and i have a point to make)


here's the thing. i'm quite entrenched in regards to structural analyses of the american healthcare system, specifically in regards to its expense, inefficiency, byzantine bureaucracy, and obfuscation. at least i understand the issues on an abstract level. comparative analyses usually provide real empirical facts (costs, services) as to the horrors of american healthcare compared to universal healthcare/single payer/german model/whatever. but they rarely go into the concrete minutiae of the insurance system. i am in this case, because of efficiency, far for public healthcare over the hellscape that's states healthcare.

however, again, when it comes to the minutiae of the system, dealing with the details of navigating insurance; understanding ideas like deductibles, out-of-pocket, qle's, and so on... my eyes have always glazed over. isn't this a black spot irt what i believe when it comes to healthcare? i usually appeal to understanding & dealing with the concrete, and here i'm tied in comparative papers of modeled abstractions rather than understanding the minutiae of the system. shouldn't i intricately learn how the system works, its material procedures, before criticizing it?

so ok. i watched an upbeat (simultaneously fever dreamscape) rundown of the system. i got an overview of it. (yea yea it's bdg, but i've previously seen & read drier rundowns elsewhere.) now, on the other side of watching... i still have no clue about the minutiae of it. and i'm not going to remember it, as i was unable to before. my brain will find it too difficult, and i'm more concerned with my pasta.

so thread title. wth is a copay. i learned now that a copay is a cost you always pay out of pocket even if insured. it maxes out towards your out-of-pocket maximum, but not your deductible. and i'm not going to remember it. (and if i've still misunderstood, that's better for my point -)

thesis. let's for the sake of argument presume there's an option for everyone in the united states to get healthcare that's cheaper than & as efficient as the tax-funded stuff people do elsewhere. we'll call it a tailored service. maybe it's even stellar in comparison to the public option. and when discussing healthcare, sometimes people appeal to the tailored service. it's private choice of services, the shrewd individual at its finest. the appeal is to the concrete world of being; statistics don't necessarily matter to the individual. if you manage to understand & deal with the concrete, you'll identify the superior option.

however, i don't see that as relevant at all. it all comes down to obfuscation, which bdg of course talks about. the thing is that the language and simultaneous segmentation+overlapping of options makes the concrete so adverse that the system necessiates abstraction. the services themselves refuse to let me deal with them concretely.

so my point is, i don't have to know what a copay is. because they refuse to make it parseable. understanding what good a copay can do for you is completely irrelevant as to the viability of the system; the tailored service is impractical and bad.

(sidenote: it's not because i'm a dirty foreigner; american healthcare is an absolute jargon of nonsense, obviously full with traps even for the americans themselves, where every shred of the system refers to something else as a schrödinger's option; simultaneously a hindrance or an option until observed; and the available services themselves opaque with tiered options and asterisks at every damn corner of the document. avalanches of acronyms ptsdbbq.)

now imma make pasta. and the americans parsing this don't have that luxury.

thread topics/discussion: is my stance a fair one to have, and would it be good to do away with the current system and replace it with eg a german or nordic model
 
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Co-pay is one of the easier bits. Just assume it's always expensive. Insurance only covers the preventative stuff mostly easily.

Referral chains give me headaches.
 
It usually refers to an up-front fee, supposedly nominal, that the insured pays for each office visit. I think (in the USian system, which you're not wrong is f-d up) it's just meant to put a drag on making too many office visits. You've got some skin in the game.
 
It usually refers to an up-front fee, supposedly nominal, that the insured pays for each office visit. I think (in the USian system, which you're not wrong is f-d up) it's just meant to put a drag on making too many office visits. You've got some skin in the game.
have to ask about the practical purpose of this - who would be abusing too many office visits? hypochondriacs? how many are there of them?

also (positive) shout out to farm boy for introducing me to the concept of referral chains, which i'm not gonna research, i'll refer to the point of this thread.
 
The frustration levels of the US healthcare system are closely tied to the insurance program one is part of. Better insurance is much less frustrating than less good plans. I've had pretty good employer sponsored healthcare plans for most of my adult life: small copays, good doctor access, sometimes a deductible sometimes not. There are many options and price points in the US system and they can be very different. Currently as a retired person I have Medicare plus a supplement plan. I have Supplement F which is one of several choices possible. I have a small annual deductible ($500) and pay $120/month for Supplement F, plus $2000 annually for Medicare B. I have no copays and all my medical appointments and tests are free. So I pay about $4000 a year for all my healthcare events which include: 5 different doctors (most of whom I see once a year); tests, and any procedures. My open heart surgery and five day hospital stay in 2014 cost me $3000. I have one drug I take regularly, (an eyedrop for pressure) that I have to pay for out of pocket that costs $30/month.
 
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have to ask about the practical purpose of this - who would be abusing too many office visits? hypochondriacs? how many are there of them?

also (positive) shout out to farm boy for introducing me to the concept of referral chains, which i'm not gonna research, i'll refer to the point of this thread.

I'm guessing they aren't unique. But a quick summary goes: there are HMO plans and there are PPO plans. PPOs generally cost more and are more flexible. You can see, generally, whatever medical people you want and the insurance covers a percentage of the cost. HMOs generally cost less, and cover higher percentages of fees once all is said and done. But you can't go just anywhere. You have a home doctor, or primary care physician, who is probably a generalist. So family practice, or internal medicine, or a pediatrician. That sort of thing. If you need to see a specialist, the insurance will only work if you get a referral from that doctor to the specialist in thier corporate network. If that specialist needs another, different specialist, they then need to refer you to that. This all needs to be in writing, because insurance will routinely out of the blue reject these charges. So you might wind up 3 or 4 referrals deep, and if the doctors all made you come into the office, that's 4 days out of work and four different, you guessed it, co-pays.

It's a routine sort of headache, and if you're alone and trying to do this while seriously ill, you're probably just ****ed. Assuming the medical stuff goes well, you can catch back up on all the stuff you let slip when collections starts destroying your credit, because the billing offices for the medical networks forwarded you on when the insurance didn't disgorge.
 
Basic health care terminology:

premium: a monthly amount you pay (or that is deducted pre-tax from your paycheck) in exchange for enrollment in a health insurance plan

deductible: what you have to pay before insurance starts paying for stuff

co-pay: an amount you pay for health care as a flat fee (with the health insurance company paying the rest). Depending on the plan and treatment, some treatments are flat co-pays (say, $10 co-pay for generic drugs for the year), some require you to meet the deductible before the co-pay kicks in.

coinsurance: like copay, but you pay a percentage of the total cost, rather than a fixed, flat fee for all procedures of a certain category. So rather than “after deductible you pay $10 for such and such type of drug,” it’s “after you meet the deductible you pay 10% of whatever the cost of the drug is.”

Out-of-pocket max: the threshold cost at which point the insurance begins paying out 100% of all costs.

HMO: an insurance plan, usually offered by large hospital networks, where you pick a GP, and then require referrals from that GP for any specialized care. Usually the networks are smaller (with little or no coverage for out of network or care without referral), but the deductibles are lower, and the co-pays are pretty reasonable

PPO: the insurance company contracts with various hospitals, you don’t need referrals, you only need to go to services that are “in-network,” i.e. accept your insurance

HSA: a health savings account, only available if you’re on a health insurance plan with a high deductible, you kick in some amount of your paycheck pre-tax (with some matching arrangement from your company), which you can then use for health care spending. That amount rolls over year-to-year and and follows you if you quit or are fired. You can think of it like a 401k that you can draw from pre-retirement tax-free for certain expenses.

FSA (flexible spending account): like an HSA, and FSA is a supplement you take to your health insurance (but anyone can take one out). When you elect your coverage in November, you select some dollar amount for the year, which is deducted pre-tax from your salary each paycheck. You can then use that account to pay for health expenses. At the end of the year any amount you don’t spend over a certain amount is erased from your balance (i.e. “use it or lose it”). The idea is if you have fixed health care costs that you know you’re going to spend for the year (like drug prescriptions), you can pay those double-tax advantaged (1. the income itself is not taxed, 2. it reduces your overall taxable income at the end of the year)

The general trade-off is plans with high deductibles will have low premiums, and coinsurance while high premiums come with lower deductibles and more flat co-pays. So for instance I have Kaiser, which is an HMO. I pay a premium of $167/mo, for which I get a $175 deductible for the year, and a $15 copay for visits, and a $2000 out-of-pocket max. Kaiser also offers a CDHP that is a $25/mo premium for a $1500 deductible and 10% coinsurance
 
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That copay definition is wrong. Copays are fixed fees for services like a doctors office visit. For example $25.00. It is usually paid upfront. Sometimes it can be a % of the allowed amount(discounted rate) for a service but is usually a fixed fee. Copays generally don’t apply to deductibles.
 
the thing is it's not really paying for level of care because it's always flat, no matter what the doc does for you.
I always assumed it's sort-of covering for administrative expenses. (as suggested, it costs nothing for anyone to constantly walk in and demand to see a doc over and over again, without a copay)

but my knowledge of the system is practically nothing. who knows what it "does"...
 
That copay definition is wrong. Copays are fixed fees for services like a doctors office visit. For example $25.00. It is usually paid upfront. Sometimes it can be a % of the allowed amount(discounted rate) for a service but is usually a fixed fee. Copays generally don’t apply to deductibles.

Sorry, yes I corrected that. Coinsurance is a percentage and copay is flat. In my experience (2 HMOs and 1 PPO), in both cases generally unless something is explicitly deductible-excluded (e.g. in Chicago all doctor visits were 100% covered with no deductible requirements), you have to meet the deductible *before* the coinsurance/copay ticks in. So for instance when I was in therapy, my first session of the year would always be $200 (the normal hourly rate for the center I went to), and then once I met my $200 deductible the sessions for the rest of the year were a $20 copay.

With Kaiser, “value-based drugs” and “preferred generics” are $5 and $20 copays respectively with no deductible requirement, while a “preferred brand” requires you to first meet the $100 prescription drug deductible, after which the price drops to a $40 copay.

Likewise, an emergence room visit is a $250 copay once the deductible has been met, while an ambulance is 20% coinsurance with no deductible requirements.
 
Co pays are so you dont go running to the emergency room for a runny nose. "Oh, I am going to pay $25 for a doctor visit or $100 for an emergency room visit? Yeah, I don't think I need to be seen for a runny nose." Something more serious, then yes, I'll go get seen.

Insurance is terribly inefficient. Hospitals and clinics will often give you a discount if you pay entire cost upfront in cash, because then they know they get paid, whereas insurance can always deny it for whatever reason and not pay, then the hospital has to go after you for payment and it can take years before you get them all their money. But most people won't have extra money lying around for treatments if they end up needing expensive treatments that run into 5 or 6 figures, so that's why everyone still uses insurance.
 
Cheaper to pay for oil changes than seized pistons. Better for the car, too.
 
they should just have it like any other insurance: "injured? file a claim. no we're not paying for routine maintenance."
What's routine maintenance and what isn't? Sounds ripe for abuse by insurance (to deny claims) like 'pre-existing conditions' were many years ago.
 
Keep in mind that when you are paying copays for services, the insurance company is still paying for the difference toward their allowed amt.

So say an Dr visit is normally charged $100. That is the provider's charge for that service. An insurance company has "network" providers that agree to their discounted rates. Say in this case that is $75. That is the total the provider will receive in payment. The copay is say $25.00 (paid up front usually) The insurance company will pay $50 for a total of $75 the provider will receive from that service.

(I consult in the healthcare industry)
 
What's routine maintenance and what isn't? Sounds ripe for abuse by insurance (to deny claims) like 'pre-existing conditions' were many years ago.
It's preventative services like routine physicals or gyn exams. contraceptive stuff. nutritional counseling. mammograms. In US, these services are mandated by the Affordable Care Act and required to be covered in all commercial insurance plans (except some grandfathered plans)

It's actually quite the opposite of a tool to deny claims. The primary issue is how providers (doctors, hospitals, etc) code their claims. Preventative services have limits like one routine physical or colonoscopy per year and 2 gyn exams per year - for example. Providers mess up coding all the time.
 
:lol: forgot about nutritional counseling.
 
There's other types of counseling as well, just can't think of something at the moment. Oh...HIV counseling is one.

edit: All kinds of immunizations apply as well
 
I forgot the statistics, but people who abuse the medical system are an enormous percentage of the costs. Even a token copay would make a difference. This is distinct from the people who need a large number of services, who are also a very small fraction of the population relative to their cost

The copay is a large part of our life. If anybody has to pay a toll on a public Road or Bridge is paying a copay. Sometimes it's to recoup some of the cost from the people who actually benefited from it. Sometimes it's to prevent congestion. Chances are your public museums are essentially copay. The fines on your library books are copay, in a technical sense. If you make books free for 2 weeks and then 50 cents for another week, all of a sudden you get to churn your books at 2 weeks instead of three.

Skin in the game really does matter.

There are some easy workarounds to the problems. Send people money quarterly that's an amount greater than the average copay total. Put a ceiling on the number of copay requirements annually.

I personally know somebody who used the emergency room instead of a personal doctor for everything until covid ruined the emergency room. Moral suasion doesn't help.
 
Keep in mind that when you are paying copays for services, the insurance company is still paying for the difference toward their allowed amt.

So say an Dr visit is normally charged $100. That is the provider's charge for that service. An insurance company has "network" providers that agree to their discounted rates. Say in this case that is $75. That is the total the provider will receive in payment. The copay is say $25.00 (paid up front usually) The insurance company will pay $50 for a total of $75 the provider will receive from that service.

(I consult in the healthcare industry)

Yes, and insurance typically doesn't deny coverage for simple doctor visits. It's the expensive treatments they will sometimes find a way to deny it.

It was many years ago, but my wife needed an MRI. Dont remember what the hospital quoted us, but with high deductible would be paying all or most of it ourselves. but could go to another private company that only does MRIs and their quote was 1600 if we used insurance, 800 if we paid cash*. But the hospital also adds other fees on top of the MRI ('doctor visit' for the operator of the MRI, 'doctor visit' for the one doing the analysis/processing of the images, 'doctor visit' for consulting with the doctor about results, etc) it cost over $3000 going through hospital.

*like I said, this was many years ago, prices may have changed significantly either way since then.
 
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