STM benefit question

[Joseph1]

My grandfathered individual plan cost has gone through the roof with Anthem BCBS and I am looking at some good(?) STM plans. ( Get Affordable Short Term Health Insurance Quotes )

Two of the covered benefits - which I do not fully understand - are the following:

7. Charges for a surgical assistance or a surgeon assistant up to 20% of the Usual and Customary allowance for the primary surgical procedure performed during the operative session.

8. Charges for the administration of anesthetics up to 20% of the Usual and Customary allowance for the primary surgical procedure performed during the operative session.

Can anyone help me understand that?
(If I have a $10k surgery and the administration of anesthetics cost $5k, what would I be responsible for?)

Thanks,
Joe

Any other thoughts on that plan are appreciated, it is going to cost $127, which is exactly half of what I am paying now.

 

[leevena]

Usual Customary and Reasonablethe amount of charge the insurance company will recognize from which to pay their portion. It is not the amount charged. By way of example, the charge is $1,000, the UCR is $700, and since the benefit is 20% of UCR the carrier will pay $140 of the $1,000. 20% of $700=$140. Amounts in excess of UCR ($1,000-700=300) is yours to pay.

If I understand your last comment correctly, the STM is $127 per month, while the Anthem plan is double that. Without seeing any of the information about the Anthem plan, I would be a large pepperoni pizza that the Anthem plan is a much better deal.

Good luck.

 

[Joseph1]

Usual Customary and Reasonablethe amount of charge the insurance company will recognize from which to pay their portion. It is not the amount charged. By way of example, the charge is $1,000, the UCR is $700, and since the benefit is 20% of UCR the carrier will pay $140 of the $1,000. 20% of $700=$140. Amounts in excess of UCR ($1,000-700=300) is yours to pay.

If I understand your last comment correctly, the STM is $127 per month, while the Anthem plan is double that. Without seeing any of the information about the Anthem plan, I would be a large pepperoni pizza that the Anthem plan is a much better deal.

Good luck.

Thanks.

In your example wouldn't I be responsible for 700-140=560? Otherwise who would pay that amount?

There weren't many holes in this plan that I was uncomfortable with. This is a 1000/0/1000/1000000 plan whereas my Anthem plan is 1500/0/1500/1000000, but obviously provides better coverage with some surgeries etc. (and renewing, which hpfly will change soon) I am just looking to see any big holes and these two benefits really confused me...

 

[leevena]

Yes to amount. Carrier pays 20% of 700 and you pay for 80% of 700.

I specialize in self-funded group, not individual. Someone else will need to chime in on comparison, but I doubt very much if anyone would recommend the STM over Anthem, at least at those prices.

 

[Joseph1]

Thanks. Sounds like a potential BIG hole.

 

[J.R.]

If you're that concerned about UCR charges it would be better to suck it up and pay double for your current plan to have that piece of mind. However, If you're willing to take the risk and possibly pony up the money later on pick the STM plan. They're the equivalent of a catastrophic plan, but without all the bells and whistles.

 

[yorkriver1]

There is probably a maximum out of pocket based on usual customary and reasonable in the BCBS plan. Most of the grandfathered types probably pay a much larger % of UCR than the lower cost plan you are considering. It's kind of flipped over, where you pay the larger % of costs on the lower cost plan. The price you are being asked to pay on the grandfathered plan is probably pretty good for the coverage compared to plans you would get that would exclude pre-existing conditions, and get very picky about that at claim time.

 

[rcduggan]

this comparison is ridiculous, sorry. why not just settle for an ACA plan?

 

[yorkriver1]

ACA has become a luxury catastrophic plan. After the maximum out of pocket is met, then unlimited coverage, with very few exclusions, assuming the ACA plan claims are from the plan's in network providers. All the other non ACA plan options will pay less in a large or small claim and often a huge amount less.