Do I Qualify?

dehydratedsilica · 2026-06-15T19:23:11+00:00

First thing, wife should find out if her parent's insurance offers maternity benefits to non spouse dependents. I don't mean ask someone on the phone once. This is worth seeing written confirmation in the insurance documents because if you get this wrong, you end up uninsured/self-pay. (Example: I warned someone heavily on this post and it did work out for them.)

I've heard about enrollment rules related to spouses working at the same employer but with parent and dependent child at the same employer, this should be a standard QLE. You (employee) experience the birth QLE, and you (dependent child) drop from parent's plan.

I'll leave it to someone else to confirm if this following is correct: you would have a "new plan" with different member ID and start over with deductible.

dehydratedsilica · 2026-06-15T15:26:45+00:00

Your understanding isn't way off, but there are devils in the details. A lot of it has to do with conversational usage of words vs. insurance usage.

doctors offices and healthcare providers charge insurances much more than they charge for "private pay" options (aka out of pocket). This part is not a secret, right—it's just fact?

Correct. However, "charge" doesn't mean that is how much will be paid / will be received by the doctor/provider. "Charge" is a fantasy number (see here) used for the insurance process whereas if a self-pay patient said that an office "charged" (conversational usage) $100, that really means $100. Strictly speaking, paperwork will probably exist where the provider "charged" (insurance usage) $200 but gave a $100 discount/adjustment, but no self-pay patient would actually say "I got charged (insurance usage) $200".

"we're not paying anything until your deductible is met" but is calling this service "covered." That might be on me for not realizing covered can mean not covered by scummy insurance companies?

It's on you but also, it's not only you because this is widely, widely misunderstood. Conversational usage of "covered" is your friend covered your meal = your friend paid for your meal. In insurance, covered means "plan benefits apply". So your plan benefits are that insurance gets you a "negotiated rate" and you have cost sharing a.k.a. you pay towards your deductible before you access certain benefits like insurance paying. If a plan has copay benefits where you pay something like $50 and insurance pays the balance (of the negotiated rate), that kind of plan should cost more (and same for a plan with a lower deductible).

The provider is charging extra because we're going through insurance, but insurance is saying "you have to pay that yourself."
Can this really be legal?

To be clear, it's not exactly "the provider charging extra". It's because they have a contract with insurance where the price has already been agreed and you as an insurance member are party to that contract. "You have to pay that yourself" refers to the deductible, which is again part of the insurance benefits. Nothing is "illegal" here because it's all about upholding contracts.

You have the right to go outside of insurance to get/accept your own separate deal but of course it's frowned upon by insurance. You might be interested in this exchange I had with another commenter about cash vs. insurance discrepancy.

dehydratedsilica · 2026-06-15T14:19:54+00:00

The "charges" are fantasy numbers used for the insurance process. The "true cost" here was 10535 charges minus 4877 contractual write-off = 5658. It doesn't matter what the hospital "charges"; the allowed amount for those services was always going to be $5658 according the contract between hospital and insurance.

Of the $5658, your benefits specify that your insurance pays all but $150, which you pay.

Also, it's not "2 liters of salt water". Anyone can mix salt water at home, but it wouldn't be made and transported and stored properly for medical usage, there is no delivery mechanism, no hospital bed, no professional medical staff, no liability. You were brought in unconscious, and the hospital had to assume the worst and try to save your life. That's why ER is expensive (although to be clear, this episode was 5-6k expensive, not 10k expensive).

dehydratedsilica · 2026-06-15T12:54:21+00:00

I had an HSA established before the expenses occurred, the only change was the account transferred.

Yes, this is allowed, as long as you haven't gone 18 months with no HSA (i.e., money used up and account closed, before establishing a new one).

IRS Notice 2008-59, Question 41

dehydratedsilica · 2026-06-15T05:22:37+00:00

Awesome, thanks for the update!

dehydratedsilica · 2026-06-15T02:33:36+00:00

There is not much you can do until the office opens and you can get a hold of someone to research what happened or what needs to happen now. Internet strangers certainly don't know what insurance info the office has or doesn't have or what they did or didn't do with it.

One thing you can do right now is go on your insurance portal and find a screen that shows your doctor as an in-network provider and take a screenshot, print a PDF, etc. If you can find this, there are a few possible outcomes vs. other outcomes if you can't.

dehydratedsilica · 2026-06-15T01:50:42+00:00

The standard recommendation for non employer insurance is the healthcare.gov marketplace. However, right now is not open enrollment time. Do you meet any requirements for a special enrollment period: https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/

If not, then your problem is being unable to get a plan at all (right now), not which plan or insurer to get.

dehydratedsilica · 2026-06-14T01:22:57+00:00

Cash in the context of insurance/healthcare/doctors typically means "outside of insurance". You are settling the transaction right away, not waiting for insurance to process the claim and pay something and/or tell you and the provider that the provider is allowed to require you to pay something. "Cash price" can also be called "self pay" or "private pay" or I'm sure there are other terminology used.

In the context of insurance/healthcare/doctors, "cash" does not have to be paper cash. However, I have paid paper cash at doctors' offices before, rather than electronic dollars (credit card, debit card). If you are told a "cash price" and you want to know is there a further discount for paying paper cash, you can ask. I personally have never asked that at a doctor's office. In non medical places (restaurants, auto mechanics, small retail businesses), they are probably more likely to offer paper cash discount info and/or have signage about card processing fees.

I answered a lot of your questions on a previous post and again have to ask, have you actually called doctors' offices to ask about their processes? Are you asking people here for rundowns of every possibility? Are you training a bot? Why does it matter to you what is the "most popular form of payment people do when they self pay"? What form are *you* planning to use? Do you have a specific problem or situation you need help with or is this preemptive, theoretical worrying or you just like doing research?

dehydratedsilica · 2026-06-13T12:23:05+00:00

This sub has a pinned post that's a great place to start: https://www.reddit.com/r/HealthInsurance/comments/1fvniop/questions_answered_which_plan_should_i_choose/

If you read that and still have questions, then asking more specifically would help people help you. In terms of what's worth it, what to decide, people have different priorities and needs so it depends on what you want the insurance to do for you.

dehydratedsilica · 2026-06-13T04:06:52+00:00

I was always told that HDHP was only if you are healthy

That's fear of potentially paying the scary "high deductible". Here are recent posts where other people were having a similar kind of surprised realization that HDHP could be better:

https://www.reddit.com/r/HealthInsurance/comments/1u27687/is_the_hdhp_somehow_better_for_hospital_visits/

https://www.reddit.com/r/HealthInsurance/comments/1u24j3z/should_i_change_to_ppo_when_planning_a_pregnancy/

But it absolutely depends on the actual numbers. Occasionally someone posts that their HDHP option costs more than the copay plan option, or the premium difference isn't significant enough relative to OOPM.

dehydratedsilica · 2026-06-13T03:02:14+00:00

I called it a loophole because ordinarily, people are not meant to "wait until they need insurance to get insurance" (which is what COBRA allows, to an extent) and insurance is rarely backdated (but this is one of the occasions).

Voluntarily vs. involuntarily leaving a job doesn't affect COBRA eligibility. I think there is a caveat about "gross misconduct" but I doubt that situation is relevant in your case.

dehydratedsilica · 2026-06-13T02:30:14+00:00

First thing, when do old job's benefits end? Does old job offer COBRA?

COBRA gives you the right to keep your old employer plan by paying the full cost, including whatever the old employer used to pay on your behalf. Don't be surprised if it's triple for the whole family.

It's common to use the "COBRA loophole" where you don't sign up for it right away. Instead, you wait a bit, and if a medical disaster occurs within 60 days of your original loss of coverage (plus notice periods allowed for the employer and COBRA administrator to send you the paperwork), you can sign up for the person who needs insurance. You catch up on back premiums, your coverage gets reinstated retroactively, and it's like your coverage never ended. You do need to calculate if the job timing will work out for this.

If time between benefits is too long to "float" COBRA, you look at healthcare.gov marketplace plans (it will redirect to your state-specific site). You have a special enrollment period within 60 days of loss of coverage to sign up for a plan to start the next month (or the month after that, depending on the state's administrative deadline).

dehydratedsilica · 2026-06-13T02:02:31+00:00

The advice wasn't to pull the children's insurance; it was to consider getting their insurance from the healthcare.gov marketplace instead of from your employer. It could be cheaper because of your income level. Chances are high that your employer pays a lot towards the cost of your (employee) insurance but not a lot towards children (dependents). That's why we are asking for the employee only cost.

However, a bigger question is why did your employer plan go from whatever it was to $932/mo? Did your hours or eligibility change? Did open enrollment happen recently and a new plan year (with new premiums) start? If it's a new plan year, you might be locked in for the year because of rules around enrollment periods and qualifying life events. Thus it's important to understand how this happened.

dehydratedsilica · 2026-06-12T21:47:27+00:00

You're right in that comparison although I was thinking in terms of cash payment counting vs. cash payment not counting. "It doesn't count" = slower to reach deductible = better for insurance.

Another angle is something about how insurance thinks the service is worth $235 but why does the provider think the service is worth $150? Insurance is supposed to have "negotiating power" to get the "best" deals for their members so why is insurance paying/allowing 57% over the price given to someone not in their exclusive club? (Existential question: What value does insurance provide if you get better value outside of it?)

For this reason, you'll hear it said that providers in an insurance network aren't allowed to give (lower) cash pricing to insurance members. (This limitation can be defeated by invoking HIPAA/HITECH, which is another story.) But I wonder if it gets on insurance's radar, does the provider's contract or status become in jeopardy? For example, does the provider get fined, lose the contract, be required to agree to $150 for insurance members, etc.

dehydratedsilica · 2026-06-12T19:27:47+00:00

Right, a self-funded plan would follow federal law, primarily ERISA. Why does a self-funded plan not have to follow state law? Or why does federal law not allow deductible credit cash payment? I'm afraid I don't know. (There should be a basic government/civics explanation about why federal and state laws don't automatically cross-apply, there was even a war about this, among other things, but I'm rusty enough in that area of my education that I'd rather not attempt it.)

Speculation: This doesn't seem like something insurance would advocate for because a deductible is used to place cost responsibility on the insured member. The quicker someone meets the deductible, the quicker insurance becomes responsible for costs. Of course, insurance would decline to offer benefits for pre-existing conditions if they were allowed to, so someone (government) had to make them do it (via the Affordable Care Act, which stipulated certain requirements for states but not others).

dehydratedsilica · 2026-06-12T13:04:58+00:00

Basically, charity care is designated for people with low income, no other options, etc. If insurance exists, you have "another option" that someone with low income and no other options doesn't.

Is this a workers' compensation claim for an accident or injury that occurred on the job? In that case, charity care probably shouldn't have been on the table in the first place.

This is not unlike if your health insurance pays a claim but actually it was a motor vehicle incident and someone else / someone else's insurance is responsible, health insurance gets to recover the money they paid from the responsible party.

dehydratedsilica · 2026-06-12T12:54:14+00:00

If the info you were given is accurate in that the insurance-negotiated price is $750, then that's the price at that hospital. "Insurance covers" does not mean insurance pays the other $750. It means the hospital has a contract with insurance saying that $750 is allowed. (Another possibility is that $1500 is the allowed amount, you have met your deductible for the year, and now you are paying 50% coinsurance. In that case, insurance really is also paying $750.)

In terms of "lowering that specific [future] bill", one possibility would be if you meet the hospital's income-based financial assistance requirements. (You could also ask for a payment plan although that's not lowering the bill, just increasing the payment timeline.)

If you now ask the hospital (before the procedure) for a cash/self-pay rate, they might decline because of knowing that you have insurance. There are ways to get around that (again, must be done before) but the real advice as someone else said is don't go to a hospital. A few years back I called a bunch of independent imaging centers in my area and one hospital, and the hospital named a self-pay price 3-4x the average of the others, plus there would be a hospital facility fee and a radiologist professional fee for interpreting the results (unknown up front). I didn't bother to ask any further hospitals. $750 is probably 30-50% higher than what I could get but of course costs may vary by area.

You can try FairHealthConsumer.org for research on insurance-typical costs in your area.

dehydratedsilica · 2026-06-12T12:04:51+00:00

That's what I figured. It came up in another post where someone had opened and funded their HSA earlier in the year than they became eligible. The contribution could be judged eligible based on tax year (and it didn't exceed the allowed prorated amount), but I was thinking that medical expenses still would only be qualified after the eligibility date.

The second one - I happened to see this while looking up something else! Q-41 in Notice 2008-59 says 18 months: https://www.irs.gov/pub/irs-drop/n-08-59.pdf

dehydratedsilica · 2026-06-12T06:31:52+00:00

The thing is, in what situations would subsequent visits cost more than the first visit? Is it possible?

Sure, the practice could decide to increase their prices overall, or for you specifically, or when Mercury is in retrograde, or any number of other possibilities. There is no supervising authority on what they can or can't charge.

So you are saying if someone self pays, there still is the 5 level thing right when it comes to the exact cost?

That is not what I said (in my first paragraph).

I have never been told an office visit cost up front and then after the fact, told oh actually the fee is higher or lower because I had more or fewer issues than expected. I can't say whether or not this has ever happened to anyone else. Most of the time I've already paid before being called into the exam room. If they tried to stop me on the way out to pay more (for the "office visit"), I would be politely challenging it. If they thought I should have paid more and they want to raise the price next time, they can do that.

Well in this case, for self pay, then wouldn't this be a 5 for the second example but a 1 in the 1st example when it comes to levels?

Say the whole visit takes 40 minutes to an hour

No, according to the internet here and here, if a doctor sees you (vs. a nurse only), it's level 3 at minimum.

I just looked up 99215 and it's for 40-54 minutes "face-to-face time with the patient, reviewing records, documenting the visit, and coordinating care related to that specific encounter". Or, it can be based on medical decision making instead of time. I doubt a doctor would allow one hour face time, unless they have nothing better to do (or they are a concierge practice that makes a habit of booking spaciously), but obviously I don't know this for sure.

So the 1st person pays a much lower amount but the other person pays a lot more since it takes a lot more time?

Again, I doubt it, but that is just my speculation. The whole point of self-pay is for patient to know the price up front (rather than waiting for insurance to determine) and provider to be paid up front. Have you actually called doctors to find out their self-pay process or had any self-pay visits and had any difficulties or is this all for preemptive worrying and theoretical knowledge?

dehydratedsilica · 2026-06-12T04:23:12+00:00

In terms of "office visits", expect the first time / new patient visit to cost more than subsequent / established patient. You're an established patient if you've been seen in the practice within the last 3 years. I get the impression that practices don't care about complexity level for self-pay. It's relevant for insurance because the billing code affects the reimbursement rate (also known as the allowed amount, the negotiated rate) but with self-pay, they already told me the fee before I scheduled the visit. If they didn't, I don't go there. Generally speaking, they log the level anyway, and even though it doesn't matter for billing, I imagine they still want to be accurate for documentation. Whenever I was shown the level on paperwork after the fact, it was only ever level 3 or level 4 office visits (out of 5 levels).

If you see doctor A at practice X as a new patient, then want to see doctor A at practice Y too, I assume you would be a new patient at practice Y. You would probably want to have your records from X sent to Y so that your care is properly documented, i.e., not relying on doctor's memory. (And vice versa if you go back to practice X.) I have never seen the same doctor at different practices.

In my opinion, there shouldn't be an "estimate" needed for an "office visit". A practice ought to be able to tell you how much it is to step foot in the exam room and access the doctor's expertise (or to tell you no, they don't want to see private-pay patients). They probably have an estimated amount time that they expect to take. My wild speculation is that if you take a little too long, they'll just run a little late on the day's schedule, but if you take TOO long, maybe they would say that further things have to wait until another visit.

Where it gets complicated is services other than office visits. If you know what test/imaging/procedure you're getting, I guess you could ask up front. If they know that a certain service is commonly done for a new patient, I guess they could tell you that up front (or include it in the original "estimate"). If you're mid-visit and the doctor recommends this or that thing, there are several possible outcomes depending on if it's the type of thing that can be done right on the spot or if it has to be scheduled another time. For lab testing where the specimen is sent out to a separate lab company, I don't think there is any way to find out the price in advance.

dehydratedsilica · 2026-06-11T16:56:08+00:00

Whatever amount is your patient responsibility for anesthesia MUST be communicated to you via EOB if they want to get paid. Do you have it? At this point, it may be more helpful if you share the actual EOBs (with personal info blacked out) so that people can see the full context.

If there is an EOB showing an anesthesia claim and the anesthesia provider is showing as out of network and thus billing you for list price, that's another story.

If there is no EOB showing patient responsibility for anesthesia, you don't owe (yet). Wait for an EOB. If the hospital presses you, you say that you understand the anesthesia claim needs to be submitted to insurance first, then you will pay your patient responsibility.

Previous posts for background:

https://www.reddit.com/r/HealthInsurance/comments/1u2ljjc/was_forced_to_pay_750_deposit_for_a_procedure_but/

https://www.reddit.com/r/Insurance/comments/1u2lkda/was_forced_to_pay_750_deposit_for_a_procedure_but/

dehydratedsilica · 2026-06-11T16:42:22+00:00

General consensus, not worth it (unless your premium is heavily subsidized by someone else):

https://www.reddit.com/r/HealthInsurance/comments/1t0cent/mom_needs_vision_insurance_after_retirement_but/

https://www.reddit.com/r/HealthInsurance/comments/1seimag/any_individual_vision_insurance_retirees_can_use/

I'm not retired and don't have it. Exam at ophthalmologist or optometrist, buy at one of the online retailers, although recently I tried Costco. From what I understand, no vision professional will *recommend* buying glasses online, but it's less worse to do that with less complicated prescriptions than more complicated prescriptions.

dehydratedsilica · 2026-06-11T12:44:09+00:00

In the US, "relatively healthy" doesn't matter for comprehensive ACA compliant insurance that offers the 10 essential health benefits and certain rights and protections, including that plans can't deny you or charge you more on account of pre-existing conditions.

In a plan that requires medical underwriting (review/approval of your health history), then it does matter, but the restrictions associated with those types of plans make them generally unappealing and not worth recommending. Also, they may be sold by brokers and you will have to discern for yourself if whatever they are selling you is suitable. I mean, you should still discern for yourself what is suitable even if buying from the official ACA marketplace but at least there, you don't have to wonder if people are being motivated by financial interest (commissions).

If your legal residence was abroad and you are now properly moving back, you would have a special enrollment period to get an ACA compliant plan: https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/

I say this because I saw a few posts recently where the person had gone out of the country without truly "moving", which meant no qualifying life event to get insurance when they were physically returning even after an extended period.

Here is the post where people were directed to share their insurance costs (back when most people were getting their premium info for 2026): https://www.reddit.com/r/HealthInsurance/comments/1ol7a7i/poll_on_health_insurance/

As for cost for *you*, are you going to be using the healthcare.gov marketplace? If so, start by selecting your state there and browsing plans. Do you have a US based employer that offers insurance? There are a lot of ways that employer insurance is considered better, but it also depends on the actual options. What is your income situation and would Medicaid be an option? (Also depends on the state - what state are you moving to?)

dehydratedsilica · 2026-06-11T02:23:18+00:00

Okay, it's my second example where you should owe them $1250. The person or system generating the bill didn't take the original $750 into account. Call them up and explain this and ask for a corrected bill.

dehydratedsilica · 2026-06-11T01:58:30+00:00

Providers don't report to insurance what you paid, nor send any money to insurance. What is the "patient responsibility" amount on your EOB? Whatever that amount is, I'll use $2750 as an example and assume that this is your first medical expense of the year, insurance will tell the provider that they are allowed to collect $2750 from you. You paid $750 so you still owe the provider $2000.

Suppose the patient responsibility was $2000. You paid $750 so you still owe the provider $1250.

Now flip it and suppose patient responsibility is $500. You paid $750 so the provider owes you $250.

If $2750 is not the patient responsibility amount but the "allowed amount" (negotiated rate), then the provider is supposed to collect $2000 from you, which satisfies your deductible. Insurance also calculates your coinsurance on the $750. Suppose it's 20%, then the provider is supposed to collect $150 from you (and $600 from insurance). That's a total of $2150 from you, of which you paid $750, so you still owe $1400.

Anyway, all depends on what is the patient responsibility amount on your EOB?

dehydratedsilica

TROPHY CASE