How Going To HR Made A Health Insurance Co-Pay Hike Less Huge

The beginning of a new year often brings an unhappy change: rate and co-pay hikes for your health insurance. E’s insurer made a change to ER visit copays that, given that his daughter is being treated for cancer and makes more frequent emergency visits than most children, would have cost the family a lot more money. So he turned to his company’s HR department for help…and actually received it.

My insurance, effective Jan 1, 2012, increased the ER Copay – what used to be $50 a visit is now $100 a visit for the first 3, then $200 per visit thereafter. I understand their need for this – they are wanting to discourage people from using ERs as a substitute for a doctors office or an after-hours clinic.

My daughter however is going through Chemotherapy and whenever she runs a fever she must to go the ER if it is outside of normal clinic hours at the hospital. Kids in general can get sick a lot, but with Chemo, you can’t just ‘wait it out’ – it is imperative they get to an ER because of the chemo side effects. I was deeply concerned about this increase – since it is not my ‘choice’ to take her to the ER but a mandate by her Oncologist. They are afraid of infections in her port and other issues that could cause serious problems.

I contacted my HR department which was already aware of my daughters condition (FML paperwork is on file for her condition) and they put me in touch with someone at the insurance company. I had said that since these ER visits would not be by choice, but as a result of the Chemo, that I was afraid we would quickly be paying $200 per ER visit. Their conclusion was that due to her ongoing serious condition, that I would still have to pay the co-pay of $100, but I would not be subjected to the increase after the 3rd visit.

The moral of the story is if your insurer has a similar plan in place for your ER copays this year, contact your HR department or your insurer. All it took for me was a few phone calls and a detailed email to my HR person to potentially save me quite a bit of money in
co-pays.

E. didn’t want us to neame the insurer, but it’s a national provider that you’ve most likely heard of.

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  1. goodcow says:

    Cue the follow-up story in a few months about how the insurance company plays stupid about this and how they are indeed getting hit with $200 ER visits.

    • jsweitz says:

      Exactly what I was thinking as well.
      Customer service in general says whatever they can to get you off the phone so they can move on to not helping someone else. Insurance works by delaying, denying, etc so THEIR customer service people are pros at it.

      • Phil Villakeepinitrreal says:

        Ding ding ding…if you don’t have a modification like this IN WRITING, it doesn’t exist. Period. If there’s ever a dispute, it will be his word versus theirs. And the contract he has will support their side.

        • allknowingtomato says:

          also, people should know that, when you are sitting on hold and are told “this call may be recorded for blah blah blah”, they are both notifying you that they may record it as well as giving you permission to record it yourself. I think it would be very prudent to record phone calls with business like this when you agree to terms. I managed to force Comcast to honor a deal by pointing out that i had a recording of my discussing with the CSR when i signed up. I’m sure the insurance company would get a little less dumb when you say “oh, no worries, i have a recording of the conversation where we agreed to my insurance terms.”

          • Difdi says:

            Actually, no court case has ever determined that to be true. It’s just a common sense assumption. But if you believe common sense has anything to do with the conclusions a court will come to, I have a few bridges I’ve been meaning to sell…

            • RvLeshrac says:

              The court, and the law, disagree with that, actually. The disclaimer gives *them* the ability to record *you,* but says nothing about *you* recording *them*.

              • MrEvil says:

                Unless you happen to live in a single party state, such as Texas. You can record your own phone conversations all you want and don’t have to notify the other party.

        • Difdi says:

          And even if you do get it in writing, you may still have to take the company to court to get them to honor their written guarantee.

  2. Lyn Torden says:

    Co-pays are just wrong, to begin with.

    • Nigerian prince looking for business partner says:

      You’re right. Who can afford the premiums on a policy with low co-pays?

    • Loias supports harsher punishments against corporations says:

      I don’t think you really understand the subject matter.

    • Necoras says:

      Co-pays make the consumer aware that their treatment isn’t free.

      If you want to live in a communist economy where nothing is assigned value, that’s fine, but I doubt you’ll find a decent medical system there. In a capitalist economy when you take away, or more accurately hide, prices then demand increases significantly.

      You may disagree with the price point of the co-pay, but the intent is to make you aware that the services you’re consuming does cost someone something. That concept is not “wrong,” it’s necessary for basic supply/demand economics.

      • Nigerian prince looking for business partner says:

        “Co-pays make the consumer aware that their treatment isn’t free”

        Have you ever priced out a policy with no copays? If someone is shelling out $20,000 or $30,000 year on such a policy, I’m pretty sure they’re fully aware that it isn’t free.

        • flyingember says:

          yes, and it costs 1/3 what you say it does

          • Nigerian prince looking for business partner says:

            Citation? I was referring to family plans, I should have made that clearer. Plans with no copays or deductibles don’t come cheap, especially for a family. Healthcare.gov is a pretty good baseline for pricing (just assume that every plan costs 20-60% more than the quote).

            • Loias supports harsher punishments against corporations says:

              My companies most expensive plan, total costs for family is ~$15,300 a year. And that is what the total plan costs, not the portion that the employee or employer pays. The cost to the employee happens to be ~$3800 0r $319/month.

              So 20-30k is probably more a cadillac plan.

      • LanMan04 says:

        Co-pays make the consumer aware that their treatment isn’t free.
        —————-
        Yeah, I think the almost-$1000 coming out of my pocket every month for premiums tells me that already…

      • Kuri says:

        I’m pretty sure the people who are paying over $200 for a checkup are well aware of this.

        And we barely have a decent medical system here, so nice try.

      • baristabrawl says:

        Well said. If everyone can go to the ER for free, they will. And because of laws like EMPTALA, you can’t just decide that someone doesn’t need to be seen, they need to be triaged. It’s such a mess.

      • brettb says:

        Co-pays may make people aware that treatment isn’t free, but they make people think that all treatment costs the same. Which is stupid-ass and why I think flat-rate co-pays should be illegal.

        Co-insurance – where you pay a percentage of the cost – make much more sense. An X-ray and an MRI or CT shouldn’t cost the patient the same amount of money.

        And the flip side is that with increases in co-pays, the patient’s portion for a brief office visit can exceed 50% of the real cost – without the consumer even realizing it.

        I think a health plan could (and should) be structured to motivate providers, patients, and insurers to all strive for care that is both efficient and of high quality. Most “features” of typical plans today do the exact opposite. Furthermore they promote unfair pricing of care for the uninsured.

    • Crymansqua says:

      Insurance is a joke in some cases.

      Last year my only ailment was pink eye- literally the only time I needed medical help. I pay $100/month for my insurance (employer pays $500). The copay was $30, which was fine. What wasn’t fine was being the only person in the clinic, waiting almost 45 minutes to be seen, being left alone in an exam room for another twenty minutes, and then seeing a doctor for all of 5 minutes and being sent on my way. I later got a bill. The whole ordeal cost my insurance $375. Actually, it was $405, but my insurance company was leaving me on the hook for another $30.

      • eyesack is the boss of the DEFAMATION ZONE says:

        Were you seen by an ophthalmologist? They’re on call constantly and were probably in the ED for much of your waiting.

      • Rachacha says:

        This!

        I always find it amazing when I review the insurance disbursements after a medical appointment. Consider a typical appointment for a sore throat.

        You go to the doctor or clinic, and pay your deductable, lets say $20
        You go to the examination room, a nurse takes your BP and temperature and other vital signs and lets you wait for the doctor.
        The doctor comes in asks you what is wrong, looks at your throat, orders a throat culture to test for strep throat and writes you a perscription for Amoxicillyn based on the fact that your spouse and kids also have strep throat.

        When you get the detail of benefits that the insurance company provides, you will likely see something like the following:

        Medical Examination: Submitted Cost $445 Covered Cost $30 You Owe $0
        Throat Culture: Submitted Cost $150 Covered Cost $ 5 You Owe $0
        Laboratory Work Submitted Cost $200 Covered Cost $15 You Owe $0

        The doctor and laboratory submitted $795 in expenses to the insurance company, they received $50 from the Insurance company + $20 CoPay, so either the Doctors are trying to screw over the Insurance company, or the Insurance company is screwing over the doctor, or everyone is artificially inflating costs to screw everyone else.

        If the Doctor is happy to get $50 from the insurance company, why does it cost someone $800 if they don’t have insurance?

        • z4ce says:

          A lot of it is in the way insurance contracts are specified. They apparently negotiate a clause that is something like covered cost is $45 or %95 off retail, whichever is less. Therefore, the doctor and lab have to charge absurd prices. Its kind of a form of collusion where insurance companies force people to purchase their products..

          • sponica says:

            my understanding is that insurance companies will only pay the average charge of certain services….so docs bill higher than what they will be paid to up the average.

            my last visit was billed for 160.00, max allowed 125.75, paid amount 95.75 (I have a 30 dollar copay)

        • Loias supports harsher punishments against corporations says:

          Are you sure the insurance company isn’t giving the doctor the remaining balance?

    • Dallas_shopper says:

      Our whole system is wrong to begin with.

      He shouldn’t have to pay $100 for each ER visit. He shouldn’t even have to pay $50.

      We need a single-payer system in the US.

    • Awesome McAwesomeness says:

      I think deductibles should be done away with as well. Over the years, we’ve payed thousands in deductibles and gotten little to no benefit from the thousands upon thousands we’ve put into premiums. We each have to spend $1200 in medical and $1200 in scripts–that is PER PERSON, before we receive any benefit. Even with having lupus, and my daughter’s ADHD, we never meet the deductible. It’s insane. They have made $30,000 profit off of us in 5 years and paid out zero. If they would have paid our medical claims they would have made about $15,000 in profits from us in 5 years. So, they still would have had a nice profit.

  3. Rachacha says:

    I hope everything works out for the OP, but HR just put the OP in contact with the insurance company. The OP could have contacted the insurance company directly, the true test will come when the OP receives the Explanation of Benefits form from the insurance company when he can see if their “conclusion” is actually true.

    • Marlin says:

      Not true. Many times HR will have a direct contact that handles their insruance plan.

      Calling regular customer service could have ended in “thats what the plans says…”.

      • Nigerian prince looking for business partner says:

        But many times, HR only directs you to the broker, who may or may not be able to provide any special insight. When it comes down to it, the decision will be based on the plan’s certificate and the only way HR will have any special power is when the plan is self funded.

        • Loias supports harsher punishments against corporations says:

          Not exactly true. HR is a representative of the management, and the company has the choice to pay for whatever portion of the insurance they want, so long as it’s relatively uniform. If they want to make an exception they (management) has the authority to do so.

      • fatediesel says:

        Agreed, I am somewhat involved in HR at my company and we always deal with the same person at the insurance company. She is very familiar with our plan and anytime someone needs to talk with the insurance company she is the one we put them in contact with. As someone familiar with our company I would feel much more confident in her helping our employees and potentially making an exception to the rules rather than a random customer service agent.

    • Tim says:

      Sounds like it helped to go through HR in this case. HR might have known someone the OP couldn’t have gotten in touch with or something. But at the very least, it’s HR that decides whether or not to renew the plan for the company for the next year, so it behooves the insurance company to listen to HR.

      • StarKillerX says:

        Yes, insurance companies will go much further to resolve issues when HR are involved because while you might be the ultimate consumer it is the company that selects the insurer and the plan to offer.

  4. Nigerian prince looking for business partner says:

    I wouldn’t be confident that things are resolved until the EOB is cut.

  5. JMH says:

    This guy used to only pay $50 for an ER visit? Gosh, I pay that much for a primary care visit.

    • Nigerian prince looking for business partner says:

      It’s kind of crazy that these type of Cadillac policies are still around — In my state, premiums for something like that would be in the $20,000/year ballpark for a family.

      My employer did away with copays (via PPO) and transitioned into a HDHP about 5 or 6 years ago and premiums just hit $15,000/year. We just dumped the policy in December because it was so crazy expensive. I never thought I’d be excited about a $10,000 deductible but I definitely am now.

      • KillerBee says:

        The policy in question is very good, but not what is commonly referred to as a “Cadillac” policy. Cadillac policies have terms where you pay nothing at all ever expect your monthly premium.

      • Necoras says:

        We still have something like that (high premium, low out of pocket) but you have to see only in network doctors, etc. It used to cover 100% of ER visits, but last year they added a $100 or so copay and everyone was kind of miffed over it. I found it really funny because I’m on the high deductible plan and I save enough to pay for my deductible 3 times over every year in savings from the lower premiums I pay.

        • Nigerian prince looking for business partner says:

          That’s why I opted out of the plan through work.

          By raising our deductible by $5,000, we cut our annual premiums by close to $10,000.

      • sponica says:

        I worked at a horrible non-profit and we had a decent HMO although they strongly encouraged the HSA but the price difference (at least for a single person) did not offer substantial savings for the whole time v money equation to balance out.

        The office visit copays were 15 dollars and I can’t remember the ER visit copays, but they were waived if you were admitted to the hospital which for a relatively healthy work-force who have PCPs, we’re usually only going to the ER because something catastrophic happened.

        The one thing I didn’t like about the plan was that the prescription mail order offered no benefit at all. You still paid 3 copays for 3 months of prescriptions whereas every other mail order I have used offered a discount.

        Part of me wonders if there are regional variations on expectations for what your employer provides as far as health insurance is concerned.

        • Nigerian prince looking for business partner says:

          “Part of me wonders if there are regional variations on expectations for what your employer provides as far as health insurance is concerned.”

          Absolutely. There is a ton of great info here on health insurance & medical spending by state (it’s run by KFF) here –

          http://www.statehealthfacts.org/healthreformsource.jsp

          And more general info here: http://www.kff.org

          • sponica says:

            I don’t necessarily mean the amount spent but what types of insurance are offered. Almost every non-profit I’ve interviewed at has offered decent health insurance plans at what I deem to be a reasonable cost (granted I’m single with no dependents) and I live in the overpriced northeast.

            And I looked at my last claim, the pricing seems much better than what other people here say their office visits have cost. The practice billed Anthem 160, the allowable cost was 125.75, the paid cost was 95.75. But the practice is part of the Dartmouth Hitchcock family…

    • tbax929 says:

      I decided not to take my employer’s health insurance and purchase my own. Granted, this may have worked to my advantage because I have no dependents and am in fairly good health. Regardless, I’m paying $50 less per month than I was through my employer, and my copays are $30 for office visits, as opposed to their plan, which pays nothing until the $5,000 deductible is met. My prescriptions are cheaper, too.

      • Nigerian prince looking for business partner says:

        If a group is older, unhealthy, or disproportionately female, it can lead to significantly higher rates than an individual can get on the non-group market. This is especially apparent when an employer only offers a bare minimum subsidy. The mandated minimum coverage are also typically lower (ie, things like maternity is considered an add on), which can lead to lower rates.

        The downside is losing out on the company subsidy and not getting an equivalent salary increase and losing the tax advantages of being able to buy a policy with pre-tax money, which you can’t do with a non-group plan until it reaches ~8% of your AGI.

  6. AllanG54 says:

    I think my plan is $500 for an ER visit and that’s after I pay $1211 a month for the insurance.

  7. mollyflogs says:

    My husband’s employer had to either raise the cost of insurance this year or pick a plan with fewer benefits. They opted to raise the cost modestly, at about $10 extra per month for a single plan and our family plan is $22 extra. The office visit copay went up from $15 to $20, and the deductible went from $300 to $1000.

    HOWEVER, they also added a new benefit on their own. Now, the company will reimburse you for any deductible you pay over $300, if you end up having to pay the deductible at once. So if we have an issue and we have to pay $1000 at once, we can submit the form to his HR department and they will reimburse us $700. I think this is a pretty fair compromise!

    • Rachacha says:

      I used to work for a small company, and as teh company grew, more and more employees were looking for dental insurance as a benefit. HR looked into it, and it was too cost prohibative, however, they talked to their benefits advisor and decided to self fund dental insurance. You simply had to bring in your dental bill and the company would reimburse you 80% of the bill for all dental bills up to a maximum $800/year reimbursement. For most people this was enough, and the benefits would have been less to the majority of employees had we gone with traditional insurance.

  8. tinyhands says:

    GET IT IN WRITING!

  9. John Gage says:

    Full disclosure…I work for an insurance company. Employers need to be VERY careful when granting exceptions. Part of ERISA (federal health insurance law) is that plans must be administered fairly and uniformly. If you start offering exceptions, then you need to be prepared to offer them to everyone. What if a different employee hears about this and goes to HR to ask for an exception for office call copays because their child has to go to the office a lot.

    While I certainly feel for the OP, the fact remains that her benefits are her benefits. If I was this employer, I would have told the employee that the have to follow the benefits as they are, but would help them work with the ER to see if they could waive the additional $100. More than likely the bill will be over $1000. If the ER gets all but $100 between the health plan and patient, they may be willing to eat it.

    • Nigerian prince looking for business partner says:

      On the same note, isn’t waiving a co-pay or deductible illegal for providers in many states and violates most contracts between providers and insurers?

      • John Gage says:

        Very good point. Here in MN by law pharmacies cannot waive copays but I know of no such law regarding MD offices.

        • Nigerian prince looking for business partner says:

          It would be interesting to see a state-by-state breakdown but I can’t seem to find anything.

          In West Virginia, the laws about deductibles and copays are always prominently displayed. The same laws seem to also apply to autobody and autoglass shops.

  10. Not Given says:

    Keep all the correspondence and notes on phone calls, including who you talked to and when, copied in triplicate. Hell just scan it in so you can print out an extra copy any time you need one. My pre approved shingles vaccine was denied after the fact and I was able to get it paid.

  11. yurei avalon says:

    I partially work in the HR department at my job and we encourage the employees to come talk to us if they are having an issue with their insurance, especially when it comes to billing/covering things. If the doctor’s office codes a visit incorrectly for instance, and the insurance rejects the claim we will get in touch with the insurance company and our corporate office if need be and go to bat for the employee to get things fixed.

    Being a subsidiary company of one of the largest companies in the world doesn’t hurt our clout either at times I think. No one’s heard of us, but as soon as we say, “We are a subsidiary of such and such” the light comes on. :D

    I will say though, people are so annoying when it comes to their insurance policy. You give them months and months of notice about changes to the policy, paperwork they have to sign and when they can make changes to their plan and they still wait until the last minute to submit changes or do things or usually until after it’s too late to do anything about it. Then they cry because they are getting too much taken out each week because they didn’t change plans or go get their psychical for the discount or whatever. So irritating.

  12. waystland says:

    Thank god i live in Canada, i pay nothing, my employer pays for the “extra insurance for glasses braces dental and Meds all i do pay is $2 dispensing fee, but hospitals , walk ins , having babies broken bones x rays just walk in and walk out..
    i cant imagine how a health problem can ruin a family finances.

  13. dush says:

    Ironic that it’s called an FML form. Or maybe not ironic?

  14. ned4spd8874 says:

    It’s all a scam. Sorry, but my company has BCBS (which is the total WORST insurance I’ve EVER had to date and I’m 37 so I’ve had many different companies) and our costs have recently gone up.

    Not only are we paying more out of each paycheck, but now they made us add our auto insurance as primary medical if we are in an auto accident. Which, of course, makes my car insurance go up. So not only am I paying more for service, but I’m getting less. I’m paying about $100 more per month now. It’s just a joke.

    I really want to quit my job because of how bad this coverage (or non-coverage) is!

  15. chatterboxwriting says:

    This kind of stuff is why I quit the HR field and never went back. At my very first HR coordinator job, I was in charge of telling 200 people that their benefits had been cut substantially AND that prices were going up substantially. I have chronic health issues, so I really felt for all of those people. Some of them went from paying $400/month (family plan) to $800 per month, and the deductible increased to $4,000 per year. I just felt so shitty having to break the news. Now I work from home so I don’t have to give people bad news. :)