Making up for a high deductible with accident insurance in Nevada

A high deductible keeps a health plan’s monthly cost down. The trade is that after an accident, you can owe thousands of dollars before your health plan pays much of anything. If you live in Nevada and buy your own coverage, or have a high-deductible plan through work, that may be the part of the year that worries you.

Accident ExpenseGuard is an accident plan underwritten by Golden Rule Insurance Company, a UnitedHealthcare company. After a covered accident, it pays cash to you, based on the actual charges for your care. It pays regardless of what your health plan pays, and the money is yours to use as you see fit. You can put it straight toward that deductible.

Here are two examples, set in Nevada, of how that worked. The people are fictional. The plan rules come from the carrier’s brochure.

How the plan pays, in brief

You choose an accidental injury benefit of $5,000, $7,500, $10,000, $15,000 or $20,000. That is the most the plan pays for each covered person in a calendar year, and it starts over each year. Every plan also includes an accidental death and dismemberment (AD&D) benefit of the same amount, which is a lifetime maximum.

Each payment is worked out the same way:

1. Start with the actual charges for covered care. The plan takes these from the Explanation of Benefits (EOB) your health plan sends you, after its adjustments, discounts or allowances. If there is no EOB, the plan uses what the policy calls Reasonable and Customary charges.
2. Subtract a $250 deductible. It applies per covered person per calendar year, up to two per family per calendar year.
3. Pay the result, up to the benefit level you chose.

Covered services come with time limits. An emergency room visit, an urgent care visit, burns or lacerations and a diagnosed concussion are covered when treatment is within 48 hours of the accident. Ambulance, labs and X-rays, anesthesia, MRI or CT scans, doctor visits, prescriptions, fractures, prosthetics, a hospital stay or ICU, and surgery are covered when treatment is within 30 days.

The brochure lists no separate rules for Nevada. It also says state-specific differences may apply, so the policy is the final word.

Example one: a broken wrist on the pickleball court in Henderson

Donna is 58 and lives in Henderson. She manages the office at a church a few days a week and plays pickleball in a recreational league at a city park three mornings a week. She buys her own health insurance. Her plan has an $8,000 deductible, which she chose to keep her premium down.

At 56 she added Accident ExpenseGuard, covering only herself, at the $7,500 level. Her thinking was simple. In a normal year she pays for a checkup and a prescription. In a bad year, an accident could leave her owing most of that $8,000 at once.

The fall

On a Tuesday morning in April, Donna went back for a lob, caught her heel on the court and fell backward onto her right hand. Her wrist bent the wrong way and swelled within minutes.

A friend drove her to an urgent care center that morning. An X-ray showed a broken wrist. The urgent care doctor put on a splint and referred her to an orthopedic surgeon, who saw her three days later and recommended surgery to set the bone with a plate. She had the operation at an outpatient surgery center on the sixth day after the fall, under anesthesia, and went home the same afternoon with a prescription for pain medicine. She had follow-up visits on day 13 and day 27, with an X-ray at the second one.

Matching her care to the time limits

Her urgent care visit was the same morning, inside the 48-hour window. Her X-rays, the orthopedic visits, the surgery, the anesthesia and the prescription all happened within 30 days of the fall.

The claim

The policy requires notice of claim within 30 days of the date the loss began, or as soon as reasonably possible. Donna gave notice the week of the surgery and sent her claim form with the EOBs as they arrived. They showed these actual charges after her health plan’s adjustments:

• Urgent care visit: $210
• X-rays at urgent care: $180
• First orthopedic visit: $290
• Surgery: $5,200
• Anesthesia: $980
• Prescription: $45
• Two follow-up visits at $150 each: $300
• Follow-up X-ray: $120

Total actual charges after adjustments: $7,325.

The arithmetic

Step 1. Start with the actual charges: $7,325.

Step 2. Subtract the $250 deductible: $7,325 minus $250 is $7,075.

Step 3. Check the maximum. Donna’s benefit is up to $7,500 for the calendar year. $7,075 is under that, so the full amount is payable.

Accident ExpenseGuard paid $7,075, directly to Donna.

She had $425 of accidental injury benefit left for the rest of the year ($7,500 minus $7,075).

How it met her deductible

Donna had paid $400 toward her health plan’s deductible earlier in the year, so $7,600 of it was still ahead of her. Every dollar of the $7,325 in accident charges fell inside that remaining deductible, which meant she owed all of it.

• What she owed her providers for the accident: $7,325
• What Accident ExpenseGuard paid her: $7,075
• The difference: $250, which is the accident plan’s own deductible.

Put another way, while Donna was still inside her health plan’s deductible, the accident plan paid back everything she owed for covered care except the first $250.

What the plan did not pay

Her occupational therapy. After the follow-ups, her surgeon sent her to six sessions of occupational therapy to get her grip back. The policy excludes occupational therapy. Those sessions went through her health plan alone, and the first $275 of them used up the rest of her deductible.

Anything above her level. Her claim fit under $7,500 with $425 to spare. A second accident later that year could have used up that $425 and no more.

Illness. This is an accident plan. If Donna had broken her wrist because of a stroke, the policy excludes any cerebrovascular accident.

A higher level would not have changed this claim. At $10,000 or above, the plan would still have paid $7,075, because that is her charges minus the deductible. At $5,000, it would have paid $5,000, and she would have been $2,325 short of her bills instead of $250.

Example two: a broken leg at a trampoline park in Carson City

Rosa and Ben live in Carson City with their kids, June, 8, and Theo, 5. Rosa works at a credit union and Ben teaches middle school math. Their health plan comes through Rosa’s job. It has a $7,000 family deductible, and in most years they never get near it.

They bought Accident ExpenseGuard at the $5,000 level. Rosa applied as the primary insured and added Ben and both kids, which costs extra premium. With two young children, they wanted cover for falls and emergency room trips, especially one early in the year, before any of the deductible has been paid.

The accident

On a Saturday in March, Theo went to a friend’s birthday party at an indoor trampoline park. Twenty minutes in, he landed badly after bouncing into another child and could not stand on his right leg.

Ben drove him to the emergency room. X-rays showed a broken shinbone. The ER doctor put on a splint, gave him something for the pain and referred him to a children’s orthopedic doctor. Theo saw that doctor on day 4, when he got a cast, and again on day 14 and day 28, with an X-ray at the last visit. The cast came off at a fourth visit, six weeks after the party.

Matching his care to the time limits

The emergency room visit was the same afternoon, inside 48 hours. The X-rays, the fracture care, the prescription and the orthopedic visits on days 4, 14 and 28 were all within 30 days. The six-week visit was not. As the brochure lists it, doctor visits are covered when treatment is within 30 days of the accident, so Rosa left that visit off the claim.

The claim

Rosa gave notice of the claim the week after the party and sent the EOBs with the claim form. The actual charges after their health plan’s adjustments:

• Emergency room visit: $1,350
• X-rays at the ER: $280
• Fracture care and casting: $950
• Three orthopedic visits at $175 each: $525
• Follow-up X-ray: $110
• Prescription: $15

Total actual charges after adjustments: $3,230.

The arithmetic

Step 1. Start with the actual charges: $3,230.

Step 2. Subtract Theo’s $250 deductible for the year: $3,230 minus $250 is $2,980.

Step 3. Check the maximum. Theo’s benefit is up to $5,000 for the calendar year. $2,980 is under that.

Accident ExpenseGuard paid $2,980, directly to Rosa.

Theo had $2,020 of benefit left for the year ($5,000 minus $2,980). Rosa, Ben and June each still had their full $5,000. Because the deductible applies to no more than two people in a family each calendar year, one more family member’s deductible could come out that year, and after that, none.

How it met their deductible

The family had barely touched their $7,000 deductible that year, so they owed every dollar of Theo’s care, including the six-week visit:

• Covered charges on the claim: $3,230
• The six-week visit, outside the 30-day window: $175
• What they owed in all: $3,405
• What Accident ExpenseGuard paid: $2,980
• What was left to them: $425, which is the $250 deductible plus the $175 visit.

What the plan did not pay

Care after 30 days. The visit to take the cast off fell outside the time limit for doctor visits, so it came out of the family’s pocket under their health plan’s deductible.

Equipment. For two weeks Theo got around in a child-sized wheelchair the family rented. The policy excludes durable medical equipment.

Illness. June caught a stomach bug that same month and saw her doctor. This is an accident plan, so illness is outside it.

Small injuries. A sprain treated for less than $250 would produce no payment, because of the deductible.

Matching a benefit level to your own deductible

These two stories show the same pattern from two sides. If your accident charges land inside your health plan’s deductible, you owe them yourself. Accident ExpenseGuard pays those same charges back, minus $250, up to the level you chose. The closer your level is to your deductible, the more of a large deductible a single accident claim can cover.

Some questions to work through:

How big is your deductible, and how much of it is usually left? Donna’s deductible was $8,000 and her level $7,500. A claim of up to $7,750 in actual charges would be paid back to her in full, minus $250. Above that, her level, not her bills, would set the payment.

Is it per person or per family? Rosa and Ben’s deductible is for the family. The accident plan’s level is per covered person, so each of the four has their own $5,000.

Who in your household is most likely to get hurt? Every covered person has their own yearly maximum. A family deductible can be eaten up by one child’s accident, and one person’s level is what pays it back.

Would a lower level do? For Theo’s broken leg, any level would have paid the same $2,980. Levels matter for large accidents, not small ones. The level is one of the factors in your premium, and in a year with no accident you use none of it. There is no right answer for everyone.

Can you apply? The primary insured and spouse must be 18 to 64 at the time of application. Children can be covered from birth to 25 and drop off on their 26th birthday, or as required by state. The policy is renewable until the primary insured’s 70th birthday, subject to its terms.

Remember what it is not. Accident ExpenseGuard is a supplement. It is not major medical coverage, it is not Minimum Essential Coverage, and it should not be used as a substitute for comprehensive health insurance. It also does not cover an injury arising out of, or in the course of, employment for wage or profit.

The short version

After Donna’s broken wrist in Henderson, Accident ExpenseGuard paid her $7,075, which covered all but $250 of what she owed while inside her $8,000 deductible. After Theo’s broken leg in Carson City, it paid his family $2,980, leaving them $425 for the deductible and a visit outside the 30-day window. In neither case did the plan pay for therapy, equipment or care past its time limits.

This is an outline of how the plan works. The policy itself sets the full terms, including the exclusions and any state-specific differences.