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Comment by monktastic1 | Hacker News Reader

A short conversation with Blue Shield of California last month:

BS: Have a question? Ask us via this very useful secure messaging form!

Me: Great! Can you explain the difference between these two arcane out-of-pocket limits that you display that are un-Googleable and nowhere in your documentation that I can never find anyway?

BS: Sure! We will wait two days and then send you an email suggestively titled "a response to your inquiry" that really just contains an attached PDF with a link to a completely different portal where you have to register a new account to download an image of a scanned fax that tells you to call customer service where you can wait on hold forever to answer whatever question it was you had that we also don't remember! Yay secure messaging!

Me: Wow such technology! I now very understand the difference between "out of pocket max" and "max out of pocket max"! I feel much secure that I won't go bankrupt the next time I have an incident and get treated by the wrong doctor at the right hospital! Thanks, 2022!

Fin.

View on HN

Oh wow. Blue Cross hosed that?

Max Out of Pocket: This is the yearly maximum accumulation that an insured individual must pay before the insurer takes on full financial responsibility for subsequent claims. This comes in generally one of two flavors: a family or individual.

The individual is straightforward. If you have a MOOP of $1000, and you've paid out $1000 in copays or coinsurance after meeting your deductible on just you, you no longer owe any contribution on claims for you, for that year. However, someone else in your family on your insurance will have to have their copays/coinsurance paid until either their individual MOOP is hit, or between the two of you you accunulate enough for the family MOOP to kick in, which depending on the nature of the plan, will start covering expenses for everyone else in the family unit.

Out_of_pocket_max is likely the individual MOOP. Max_out_of_pocket_max is probably a terribly named family or Group MOOP. These should not be confused with policy or lifetime maximums, which are caps to the amount of a specific benefit the insurer is willing to pay out for you as an individual period.

I know for a fact places screw that all up. I spend a large chunk of time making sure things like that do not stick around.

https://imgur.com/a/t7M2RGv

When I called, I was told that it's there to show that the OOP max for in-network and out-of-network providers isn't summed to get my total OOP max; instead it's just equal to my OON OOP max. (Of course, this plan makes it hard to go bankrupt, unlike all ACA plans. That was a bit of literary liberty.)

Ah... So they're differentiating MOOP levels they'll honor based on the provider in question.

I'm guessing they probably have some funneling arrangement that recoups the extra spend they'd incur from the potentially more frequent MOOP attainment in network.

Cute, but it really kinda sidesteps the concept of "Max out of pocket". I sense an MBA at work.

Replying here because I couldn't respond to your other comment. All the ACA plans I've looked at pay nothing for OON, so in effect there's no maximum I may pay, right? I'm curious about this redlining solution. How do you decide how much you'll pay them?

Basically, you can just piggy-back essentially on your insurer's bargaining power by agreeing to what they would agree to pay +/- a percent on top. The provider can still refuse to provide service to the updated terms of course, but it puts the ball in their court, and insulates you from "surprise" bills.

Just blindly signing it means exactly what is on that sheet of paper, that the provider settles on an amount, and you are accepting an obligation to repay it. Redlining and setting a ceiling on what you're willing/able to pay shows good faith. Which if it comes to a court case, goes a long way.

Excuse me -- your yearly deductible is $10,000? Here I thought €385 was a lot...

No, the deductible is much lower. This is the maximum I can spend out of pocket in a year. But most ACA ("Obamacare") plans have no maximum for our of network providers.

Actuallly... If it is an ACA plan, there has to be a MOOP.

https://obamacarefacts.com/health-insurance/out-of-pocket-ma...

Now keep in mind, as mentioned earlier, if you go to an out-of-network provider, and get billed for the balance of what that provider charges and your insurance won't cover, that is now between you and the provider because the insurance claim is technically complete.

This is why in some cases you may want to redline the financial responsibility statement and specify you will pay up to a set amount over what your insurer disburses. Technically, the provider can come back and grumble, but if you absolutely cannot afford to get nailed with a notorious "surprise" medical bill, that's a much more "good faith" way to approach the transaction.

It sucks... I know.

You probably pay way more in taxes. If I was given a choice between (1) an additional 20% income tax and free healthcare, or (2) crazy $10k/year out of pocket maximum, I'll choose 2 without a blink.

At the risk of turning this into a political debate -- yes, you pay more taxes if you earn more, and less taxes if you earn less.

That's how a society is supposed to work: you don't leave people to suffer because they aren't rich.

And at some point, perhaps you'll still get reasonable health care without it being tied to some employment (whether or not you were/are highly paid). Much harder to rely on that in the US.

We don't use tax money to bulk buy food, or auto repair, or fuel, or computers, or phones, or banking, or any other modern good or service that is essential and required for every member of society.

Why do we do it for health care or health care insurance? If the justification is "everyone needs it and you will die without it" then shouldn't farms and supermarkets also be public utilities? The line seems entirely arbitrary to me. Water yes, but food no? Why education and healthcare? Why not heating and electric power?

The added benefit of letting people arrange it individually is that those with a higher risk appetite are not forced into it (at significant personal expense) against their will/consent, too.

> We don't use tax money to bulk buy food, or auto repair, or fuel, or computers, or phones, or banking, or any other modern good or service that is essential and required for every member of society.

We certainly do: taxes fund social programs like welfare and subsidies, which allow every member of society to afford a baseline level of food, housing and transportation.

Back in World War II, food supplies were rationed precisely because everyone needs them, so food vendors have certainly faced regulation in times of scarcity. Farmers still receive sizable EU and US subsidies. [1] [2]

In the US, the government purchased bulk amounts of foods for decades. [3]

[1] https://farmsubsidy.org/

[2] https://farm.ewg.org/

[3] https://en.wikipedia.org/wiki/Government_cheese

> We don't use tax money to bulk buy food, or auto repair, or fuel, or computers, or phones.

We don't buy bulk food because it's a commodity with low entry costs, and between subsidies and SNAP we can keep food almost universally available. We should be doing more, because people do fall through the gaps and our agriculture subsidies could be better directed.

We subsidize transportation and oil to keep costs down. We should do more to expand free at the point of access mass transit.

There are means-tested programs for cell phones paid entirely by tye federal government (you may hear them coloquially referred to as "Obamaphones").

Many people believe basic, low cost banking services should be provided through the USPS. I believe Senator Elizabeth Warren is an advocate for this policy.

> Why do we do it for health care or health care insurance?

Health care and health insurance are different from the other examples you listed. If a person is in dire need of care, they are unlikely to be able to shop around. They might not even be in a condition to prove they are able to pay, so we require hospitals to treat people without waiting for such proof, which means providers can take on significant losses which need to be covered.

And to keep costs down in such a system where you cover these cases, it makes sense to invest in preventative care, up to the point of paying people to get it.

Entry costs to starting a hospital or becoming a health care professional are high because people want some standard of safety. This lumits competition that makes your other examples work.

> Water yes, but food no? Why education and healthcare? Why not heating and electric power?

Yes to all of the above. Since you added heating and electric, often low income will qualify someone for assistance, eapecially heating in colder regions. Since the market functions well enough for people with sone money, means testing seems to work well enough here.

> The added benefit of letting people arrange it individually is that those with a higher risk appetite are not forced into it (at significant personal expense) against their will/consent, too.

The challenge is that if you make people arrange it individually, there is incentive to underestimate the risk (higher risk means higher premiums) and then they might need care that they cannot afford. The health care system sometimes still incurs this cost because they might have to provide emergency treatment (and many conditions untreated due to costs can become emergencies).

I have 8 numbers (well... 6 and 2 'no max)...

DED-INN/OON

Me: $7k/$35k

Fam: $14k/$70k

OOP Max-INN/OON

Me: $7k/no max

Fam: $14k/no max

I regret leaving my grandfathered plan from 2010 - every year I got a threat saying it would be gone next year, then magically one more 'extension' with a threat that it would be gone next year again. And the price kept going up. Switched to ACA plan and... I missed this 'no max' stuff. Fingers crossed I don't need healthcare if I'm ... you know, outside whatever 'network' might happen to take me in for care.

> (Of course, this plan makes it hard to go bankrupt, unlike all ACA plans.

Can you elaborate on this? I'm currently looking into ACA plans and would rather not go bankrupt...

This is almost true: you will, in fact, be forever on the hook for any medical expenses charged which exceed the "reasonable" limits your insurer has set for each given service, even after you've exceeded your MOOP. So if your physical therapist charges $150/hour and your insurer reimburses $120/hour, you'll still owe $60 OOP for two hours of therapy even if you've exceeded your MOOP. Ask me how I know.

Ah, but I bet if you look carefully, it's probably hidden in the EOB or benefit booklet somewhere, if not, somebody has dome writing to do. Even then, that is not a byproduct of the insurance, but of the "Consent to be treated and statement of patient financial responsibility" form that you almost certainly signed when you went to the doctor. That 120 dollars was still paid without coinsurance or copay from you after MOOP was attained, your physician is just falling back on what you signed to make up the difference.

I hate medical billing to the point I dove in to try to figure out how it all works.

Can you tell?

This happened to me and I found the practice extremely deceptive.

In California it is nearly impossible to find therapy or similar services that don’t charge much more than the per service maximums allowed by Anthem Blue Cross (and likely others).

This is primarily about out-of-network care, but good luck finding a competent therapist in-network in the Bay Area.

For example, the max paid for a therapy visit might be $120 while the providers typically charge $160-180/session.

On my plan, out-of-network providers were supposed to be 70% covered but I only learned after the fact that coverage was 70% up to the plan max for the stated service.

How was one to know the plan max per service? Therein lies the trick, they won’t tell you until you are on the plan and even then you cannot simply ask for a list of limits by service. You have to ask one by one after you have already committed to the plan.

The plan providers do not proactively disclose even the existence of these per service limits during open enrollment, and certainly not the detailed limits.

The plan providers continue to do this year after year despite knowing full well that their limits are well below market rates. As a result predicting out of pocket costs for therapy or other mental health services is next to impossible.

It feels fraudulent and deceptive even though I suspect they have excellent lawyers who keep them coloring just inside the lines so as not to get sued.

Still, I sometimes wonder if a class-action lawsuit might be the best solution.

> good luck finding a competent therapist in-network in the Bay Area.

> For example, the max paid for a therapy visit might be $120 while the providers typically charge $160-180/session.

These seem tightly (and unsurprisingly) linked. If you were competent at your job and had a choice to bill $120/hr or $160/hr, which would you choose?

If you weren’t competent, having a steady stream of $120/hr customers pipelined to you would be mighty convenient as well.

That was my experience in fact. Therapists would participate in-network while young and inexperienced but would move out of network once they had more experience, a specialization, or a more established practice.

What that meant was if you had advanced needs you ended up paying out of pocket a lot.

Huh. Ya know what? I'm going to go look through some paperwork to see if I can find regular omissions of that sort, because now that you mention it, that seems a rather glaring omission if true.

This sounds exactly like my kids school district. They send an email telling you you have a "secure message" and you need to log in to see it. So you try to sign up to see the message, but can't because you don't have the password. So you try calling them and they say they will reply via email. What they mean is that they will send you a secure message about your inability to receive secure messages. So you call again and they transfer you to a number that is only open between 9am and 4pm on weekdays. So you call back on Monday and, because this is the start of term, can't get through, like, at all, ever. So eventually on Wednesday you get through and they transfer you again, only this time you manage to invoke XKCD 806 and get a real person who knows how to "reset" the password you never set in the first place. So you finally manage to log in to the secure messaging portal and look at the email. Oh, it's a PDF download. You download the PDF and see it's a physical letter that has been scanned in to the system manually (seriously!). The letter? The reason you went to all this trouble? It's a welcome letter to the new "secure messaging" platform, with instructions about how to reset your password...

Banking, health insurance, education

I see a trend!

It's not like Google or Amazon is better in customer friendliness. (Amazon at least has a working customer service where they get you a refund even if they have absolutely no idea wtf happened to your precious order.)

even when you keep making new accounts and "losing" the packages!

Next time just fill out the "forgot your password" form.

The one that asks for an email address and then tells you that email address isn’t in the system despite the same system sending you email? Yeah, I did. Many times.

Did you try all caps?

Similar adjustments?

Can't count how many times this kind of thing has worked.

No. No more. No more guessing, no more trouble shooting or debugging. I don't care and OP probably has more important things to do too. Sure, I can do it. Exceptionally well too! But, they aren't paying me, and users aren't shouldn't be their free, outsourced QA team.

The password reset field accepts a certain character but the login form sanitizes it differently so it won't be accepted. Or even trying to set a password with that character results in an "HTTP 50x error something went horribly wrong".

It's hard to recover from the memories of wasted time, effort, and frustration when the schools when distance-learning only in 2020.

"We will start using Google Classroom for all communication, class materials, lesson videos, live meetings, and grades"

Sure. Good. Come grade time:

"Your child is missing a lot of work. It's all due in a week."

Kid, you have to do x,y,z missing assignments listed on Google Classroom.

"Your child has already completed x."

It was marked missing on Google Classroom.

"Please refer to Infinite Campus to see which assignments are missing."

Ok...I signed up for Infinite Campus, and I don't see anything.

"Did you use the user/pass we automatically created for each parent?"

What? No.

"Sir, we sent out this information weeks ago."

Search...search...manual search...I don't see it on Google Classroom.

"Oh, we sent it through ClassDojo."

---

This is very simplified. Google Classroom required teacher-provided codes to join "classes" for each subject, provided through...school email! School email is an unused morass for Google Classroom notification emails for every action your child or their teacher makes. Get a teacher message on ClassDojo? Sorry, can't tell if it was a mass message or directed at you, so you have to clarify whether it applies to your kid given their IEP. Got two parents using Dojo? Sorry, can't see if the other parent has already responded to a teacher message. Completed an assignment on Classroom but didn't click "Turn in"? Missing. Can't find where to enter answers? Oops, your child knows to use ImagineMathExploreLinkConnect to get to that material. Completed on that fourth-party platform, but didn't go back to Classroom to click "Turn in?" Missing. Triple checked everything but still a bunch of missing assignments in Infinite Campus? Teacher is behind on grading, and there's no way to know that, either from Infinite Campus or Google Classroom, but it was in the class newsletter we emailed to your child.

Maybe not all employers, but at least mine does not realize quite how much further parents fell behind that year than those without school-age kids, on balance.

When schools excitedly announce a new platform for learning anything, I want to punch myself in the face.

I hear you man. For me the most frustrating part about all of this is each platform comes with its own algorithmic placement system that has to learn your kid's level. My eldest kid has high-IQ exceptional needs, and by the time the algorithms would learn her level and place her accurately where she would make some progress, the classroom had already moved on to the next platform. I think I counted five different platforms for math in the past year, sometimes with multiple different logins on the same platform. It's a travesty and her growth has come to a complete halt since I stopped teaching her and gave her back to the school. My heart breaks but what can you do. As a kindergartener she was factorizing numbers in the bathtub and now as a third grader "Xtra Math" is asking her to identify whether a shape is a triangle or a circle.

Seriously.

My son is the same. He started kindergarten completely comfortable with negative numbers (we just always drew the number line with both positive and negative parts) and basic algebra and only was allowed to test to enter the gifted program in third grade.

They are finally doing algebra again now that he is in fourth grade (they do math grades 3 and 4 in third grade and 5 and 6th grade math in 4th grade) but if we hadn’t set him up with a tutor a couple of years ago he’d have given up on school completely.

My younger son in 1st grade has autism (and is also gifted), to the point that he is legally supposed to have a permanent paraeducator with him at all times to help him cope with classes and physically help him if he needs help with basic tasks like holding his pencil, or realizing that he is frustrated and can’t communicate that.

Covid meant no paraeducator. Oh, they had one on the payroll, of course, but they were virtual. So the person who was supposed to help my son hold a pencil and detect he was frustrated and so on, was just a person on a zoom call.

My son lost almost a year of learning because of covid. It would have been more but we sued the school district to demand they at least put a plan in place and miraculously the day they were served with the papers, they told us “oh, we were just about to have a solution for you” and miraculously the same week, he was back in school with his para helping him with the virtual lessons.

My youngest daughter started kindergarten during covid. Everything was online. Her assignments were all in class dojo or maybe google classroom. All of the assignments had written instructions for her to follow. She was just starting Kindergarten and couldn’t exactly read well enough to follow the instructions.

All of this mean my wife and I basically spent all day as full-time teachers aides, because the kids couldn’t be left for even a few minutes by themselves. This is a difficult thing to do when also working full time.

Covid especially sucked for families with young special needs children. I think these kids were done a huge disservice.

That's a strikingly similar situation to ours. Our 4th grader has autism and needed special education services, but of course those didn't exist. At the same time, our typically developing kid was starting kindergarten virtually. At one point the teacher booted him from the class meeting because he was drawing a picture instead of writing words. She told us to ensure that he only joins class ready to learn.

All I can say is I'm glad we are all back in-person. The full-time dual-career parents as teacher's aides life was a fever dream of nearly snapping daily.

Damn straight.

As a final anecdote: our kids had a full-time gym teacher. They were supposed to have “gym” lessons three times a week.

For the entirety of covid, their “lesson” was a single powerpoint slide with the words “go play” on it.

That was the entirety of the work that needed to be done by the gym teacher for a year - post that one slide to google classroom at the appropriate times.

Generally, anything not-for-profit and older than 40 years is a technological shit-show.

There's neither the individual or management will to successfully migrate or upgrade at the pace required. Consequently, everything is held together with duct tape and person-hours.

I worked for a 80+ year old non-profit. Their tech was definitely a shit show before I turned it around. I won't be surprised if it ends up degrades into a shit show again in a decade or so.

Almost immediately after you left, they promptly lost the admin password, Phyllis in accounting said, "why don't we just go back to copy machines and filing cabinets, we know how those work" and they unplugged all your computers.

This may me hyperventilate, because I've been there - except in my case I hadn't left, I'd simply gone on holiday for 2 weeks.

> Generally, anything not-for-profit and older than 40 years is a technological shit-show.

Everything new is the same. Because everything has to be disruptive innovative hockey stick growth bullshit.

Here's a screenshot of tha app for a Swedish bank, Klarna: https://pbs.twimg.com/media/FHXG5bPX0AIC1oe?format=jpg&name=.... They are a bank. They offer credit cards, and fast online credit payments.

And no, "Payments" isn't a list of your payments you've done throught them, that's behind two or three clicks now. It's what you owe them.

What the actual fuck. If you ever come to Australia the Commonwealth Bank and Australia Post apps are two examples to restore faith in humanity.

They are functional, practical, reasonably intuitive and they keep improving with actual valuable and handy features. Every now and then it still boggles my mind when I use them.

Whenever there is a request for reviews I make sure to mention it. I hope the dev team is paid well because they clearly deserve it.

To be fair, the other bank I use, Handelsbanken, is also sane: displays all the info you need, gives you quick access to functionality etc. Not without its issues, but Klarna takes the cake :))

I heard somewhere that telegraph is a legitimate form of communication for some official routes - unless they aren't specifically prohibited. Has anyone tried this? I would reallt like to force my bank to respond to my telegraphs... or pony express letters

In the US, telegram service ended in 2006! https://www.nbcnews.com/id/wbna11147506

At my university there was a rumour that you were still allowed to submit your thesis in Latin. I think some people were tempted to try it but I’m not aware of anyone who did (or who pored over the regulations to find out if it was true)

I’m reminded of the unconfirmed stories of a student who exercised “Gentlemen sitting examinations may request and require Cakes and Ale,” and was given burgers and soft drinks but fined for failing to wear a sword.

I was told this story in Cambridge by the person piloting our gondola.

It is called a "punt".

> get treated by the wrong doctor at the right hospital!

In California, this shouldn't happen. If you go to an in-network hospital, all care providers you see are required to bill you at the in-network rate.

Great, now just do the same thing for making all hospitals in the state (and later the nation) forced to bill at "in network" rates. then with a final step of capping the premiums paid according to income with the rest automatically covered by social programs, the USA might finally get to something sort of like a sane healthcare system.

Unfortunately, I don't actually live in California.

Last time my wife went to a hospital in California, they delayed care by like half an hour over insurance and then didn't use it, so she got to spend a few days on the phone half a year later when each doctor who managed to visit the room for a few seconds sent us separate bills at the uninsured rate.

A short conversation with Medicare:

Never happened. They never pick up the phone, and they don't have any other way to contact them after you applied for benefits. I tried for weeks to resolve an issue with an application for my father, a dozen of calls, every time being on hold for hours. Sometimes the automated system says "leave your number and someone will call you back tomorrow at a certain time". That's a lie, no one has ever called back.

I feel like more an more having a lawyer on retainer is the only answer to this type of crap.

Can you bill them for the lawyer cost?

If this is what we have to look forward to when Congress eventually makes a nationwide health insurance, I’m not going to be happy

Wait, so the two examples given are someone who can't figure out what their out-of-pocket costs will be, and someone who hasn't heard back about an application, and your conclusion is that universal health insurance, which wouldn't have any out-of-pocket costs or out-of-network doctors and wouldn't have applications because everyone would already have it ... would be a bad thing?

That seems a very strange conclusion to me. Health care in the US is a mess right now, public or private, largely because of the mess caused by extreme privatization. Half of the problems people have with health care would vanish overnight if we had universal health coverage.

I assure you the full health care provided by IHS would cause a new revolution if applied to the rest of the US population.

it still will be better than what we have now. medicare spends 95% of it's budget on health care. most private insurance spends 20 to 30% on hiring people to make up reasons to deny your claim.

if we force the rich use the same system the poor use, wait times will plummet.

I know this is going to sound odd, but this is the exact thing you call your House Reps office and explain your problem. The https://www.house.gov/representatives/find-your-representati... site will give the phone number, but their website often has a local office number. Most effective Congress folks staffs know how to deal with this type of thing.

My ex job at a courthouse, handwriting documents by pencil was about as performant as using C vs python compared to the computing system. There needs to be a large computing swipe to turn the tool back into a tool and not a straightjacket. Companies incentives are just not there.

> go bankrupt /../ the wrong doctor at the right hospital

This is the real problem. If we could solve that, none of the rest would be an issue.

I thought that was already solved by the No Surprises Act that went into effect this January.

>I thought that was already solved by the No Surprises Act that went into effect this January.

Are you serious? Is this a real act? We need an act of congress to not be surprised by health care?

It seems that it is indeed real, but I suspect it will take a while before it's common knowledge and actually has teeth (but I'm a bit cynical).

Email from the dutch government: You have a message from <organization>. Log in to My Government to view.

Me: logging in to My Government using DigiD, which takes some effort, like five steps between two different sites and an app, but at least seems to be secure.

My Government message: you have a message from <organization>. Log in to <organization> portal to view message.

Me: Logging in to <organization> portal, again using DigiD (same steps).

<organization> portal message: There is a new document for you to download at My Documents in our portal.

Me: Wow, I don't even have to log in again, that's great! Document is not in the list, though. O, you have to select unread documents, otherwise you only get the old ones. Sure, makes sense.

Document: You student loan interest has been changed. We will send you your new monthly repayment amount soon.

Me: Great, glad I spent an hour finding out what was in that document...

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