US health insurance questions

The_Ink_Goddess said:

Hey guys,

So - I know that official policy varies quite dramatically, and often policy in reality and policy on paper can be two different things. So, can anybody tell me what a fairly standard/plausible health insurance response would be to this?

MC slashes her wrists. She's 16, her injuries are major. She usually lives in Missouri but she's visiting Seattle. She gets rushed to hospital. Her dad's a police officer in Missouri but he's not with her at the present moment - he obviously gets called and rushes to her as she's being treated. Is it as simple as they treat her until her condition is no longer critical, then her dad gets a bill? Also, he's a police officer - how does family members' health insurance work across state lines? (Sorry if this is a really stupid question, reps as always!)

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If he's a police officer, he most likely has insurance through his employer - the city, town or state he works for. He carries a card with his insurer's name, policy no., individual policy holder no., etc. She carries a similar card, or she should if she's a teenager. In the hospital she gives them her card, or they find it in her purse. Of course they call dad, but insurance bills are handled by the hospital through the insurer itself. Dad might get a bill for a deductible, like $50 or $100 bucks for the ER visit. But maybe not.

My daughter was in FL and had to use her insurance card for a minor health problem; she was 20 at the time and still under my insurance, through my employer. We got a small bill for a deductible from the doctor who treated her, which at the time was five bucks.

I suppose a real police officer who has had a similar problem or situation could add to this.

For my health care, I have different co-pays/deductibles based on whether the facility is "in network" or "out of network," but treatment is covered in all states.

A lot of U.S. insurance plans these days will have a deductible that needs to be met (say, $500 or $2,000), before coverage kicks in. Even then, medical expenses might not be covered 100%. We have a $4,000 deductible for the family, after which our expenses are covered at 80%. Our co-pays/deductible are expected to be paid upfront, with any additional costs billed later.

My policy through my employer has a $2,000 deductible. Where nothing is covered until that is met. Then the insurance provider kicks in 80% of costs for approved expenses. I'm responsible for the other 20% and fees the company decides it doesn't want to cover. I can argue the uncovered charges with the insurance company if I want to, but so far I haven't had to do that.

Also in and out of network facilities are covered differently. I think with mine, ER visits are okay in any facility but additional treatment and doctor visits must be in network or the insurance won't cover much of anything.

When I was briefly uncovered by insurance, I had to go to the ER in Denver. That was actually (unfortunately) easier than dealing with insurance. I just paid out of pocket on a payment plan, which seemed reasonable (unlike some of my insurance charges).

Insurance sucks.

The_Ink_Goddess said:

Hey guys,

So - I know that official policy varies quite dramatically, and often policy in reality and policy on paper can be two different things. So, can anybody tell me what a fairly standard/plausible health insurance response would be to this?

MC slashes her wrists. She's 16, her injuries are major. She usually lives in Missouri but she's visiting Seattle. She gets rushed to hospital. Her dad's a police officer in Missouri but he's not with her at the present moment - he obviously gets called and rushes to her as she's being treated. Is it as simple as they treat her until her condition is no longer critical, then her dad gets a bill? Also, he's a police officer - how does family members' health insurance work across state lines? (Sorry if this is a really stupid question, reps as always!)

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The ER will treat her if her injuries require immediate (ER) treatment, with or without insurance, whether she knows if she has it or not, yes. They're required to.

If he's a cop he likely, as others have said, has good, municipal insurance. It should cover that, less a deductible or copay or whatever, if applicable. Some plans have, some don't. Given his job, if it's a decent-sized municipality, it'd be more likely he'd have better insurance and might get a small bill to nothing.

Yeah, insurance works across state lines, but likely the hospital isn't part of his network so he'd be charged some pretty hefty out of network fees, which could be the vast majority of the bill.

You really want all this stuff for your story? Most people fall asleep when they start thinking about insurance.

There's going to be three components to this situation. First is fixing the bleeding, which is emergency room and some stitches, maybe an operation. Unless some significant complications has set in from blood loss, this isn't a big deal. This is all emergency, and most policies cover emergency out-of-area coverage fairly well.

Second component is the suicide aspect of this. If she slashed her wrists, most hospitals are going to put her on a 72 hour psych hold. This is going to be expensive, and isn't covered in a significant number of health insurance policies. Billing is done later, and dad doesn't have any choice in the matter.

Third would be rehab, which would be done when she returns home. Probably pretty much covered by his insurance.

Now I've got to go take a nap, since you forced me to think about insurance. What a yawn fest.

Best of luck,

Jim Clark-Dawe

You can take this multiple directions:

1) If he has fantastic insurance, he doesn't have to worry much about it. They treat her at the ER, they treat her elsewhere in the hospital until she's stable enough to travel, then she goes home and recovers the rest of the way there. Her father gets charged a smallish amount, but nothing he can't handle.

2) If he's got less good insurance, it's a bigger deal. They treat her in the ER, but only give her the minimum amount of care they absolutely have to until they can get her home. Her father gets a big bill for out-of-network charges, but at least the ER is covered.

3) If he's got poor-to-mediocre insurance, it could be catastrophic. They treat her in the ER and keep her in the hospital and do all sorts of tests and whatnot, and her father flies out to be with her. Then after they get home, he gets a six0figure hospital bill (AFTER insurance) because his insurance has a deductible and a cap on it and everything was out of network anyway. He has to pay the first few thousand (deductible), ~50% of the next several thousand (out-of-network doctors), and everything past ~$100K (the cap). He still gets billed at insurance rates, which is a lot better than being uninsured, but on a longish hospital stay, she might rack up $250,000 in bills and he might have to pay $200,000 of that. He either negotiates a back-breaking payment plan with the hospital for the next forty years, or he declares bankruptcy.

Seriously, any of these could be possible. They're all better than if she weren't insured at all, in which case that exact same hospital stay would all be billed to her father to the tune of 1.5-2x the amount the hospital would have billed their insurance, if they had it.

Insurance negotiated with most police unions is pretty good. Lower deductibles and coinsurance than most private employer insurance.

I, too, am interested in why you want to know about the insurance aspect. Is Dad going to yell at her for the costs?

I work for a city in Florida and have the same type of insurance as our police officers. Our policy carries a $50 co-pay for ER visits, which they will bill to us. It doesn't matter whether we visit a hospital in Florida or in another state. For ER visits, our deductible doesn't apply - they will treat us and all we pay is our $50 co-pay, regardless of how much the charges are. This isn't typical of most policies, even with municipalities, so coverage will often depend on how financially secure the particular city is.

I worked in hospital ER's on and off for years and know more about insurance and ER visits than I ever wanted to know.

First question though: Why is this important to the story? What story point do you want to accomplish with these details?

I can probably explain specific circumstances that would cover any eventuality regarding who pays, how much gets paid, whether the Mother's insurance get's involved also, etc. to meet whatever story needs you want.

In short, there's so much that could happen that whatever plot/story point you need can probably be accomodated. Just let us know what you need to happen and I can probably justify it.

I mean, if you need the insurance/payment stuff to be "painless" and handled off-screen, that's easy enough to do.

But, if you want this to cause serious financial and administrative headaches to her father (or mother) I can explain scenarios where that would happen as well.

It may be an exceptional case I think, otherwise in India where I live things are very different, may be cause of competition in market and why insurer provides great services.

I work in the insurance industry and, yes, they will treat her (and not just up to a certain point). They will provide whatever treatment she needs.

If they are unaware of any insurance coverage, the dad will get the bill. It's up to him to notify the facility of his insurance coverage, at which point they will bill the insurer for the charges.

As noted, out of network benefits generally have a higher deductible/coinsurance/copay.