Two Utah examples: accident insurance next to a high-deductible health plan

On a health plan with a high deductible, an accident early in the year, before you have paid anything toward the deductible, can leave you owing thousands of dollars before your health plan pays much.

Accident ExpenseGuard, an accident plan underwritten by Golden Rule Insurance Company, a UnitedHealthcare company, is built for that gap. After a covered accident, it pays cash to you, based on the actual charges for your care, regardless of what your health plan pays. You decide where the money goes, and it can go straight to the deductible.

Below are two fictional examples from Utah. They also cover the two places where the carrier’s brochure gives Utah its own rule.

The plan, and Utah’s two rules

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 per covered person per calendar year, and it starts over each year. Every plan also includes an accidental death and dismemberment (AD&D) benefit for the same amount, as a lifetime maximum per covered person.

The injury benefit is worked out in three steps:

1. Start with the actual charges for covered care, taken from your health plan’s Explanation of Benefits (EOB) after its adjustments, discounts or allowances. Without an EOB, the plan uses Reasonable and Customary charges, which the policy bases on the most common charge for similar services in the area.
2. Subtract a $250 deductible, per covered person per calendar year, up to two per family per calendar year.
3. Pay the result, up to the level you chose.

Covered services have time limits. Burns or lacerations, a diagnosed concussion, an emergency room visit and an urgent care visit are covered when treatment is within 48 hours. 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 notes two differences for Utah:

• The 48-hour items. In Utah, treatment is covered within 48 hours or as soon as reasonably possible.
• The AD&D window. Generally, a death or dismemberment must take place within 30 days of the accident for the AD&D benefit to apply. In Utah, the brochure gives 180 days.

The brochure also says state-specific differences may apply, so the policy itself is the final word.

Example one: a fall from a horse near Logan

Marcy is 46 and lives outside Logan with her husband, Tom. She is an accountant for a dairy cooperative, and Tom repairs farm equipment. They keep two horses, and Marcy rides most weekends from spring to fall. They buy their own health insurance. Each of them has a $6,000 deductible, then 20% coinsurance up to an $8,500 out-of-pocket maximum.

Marcy applied for Accident ExpenseGuard as the primary insured, added Tom for extra premium, and chose the $20,000 level. She had done the math on a bad fall: one of them could hit the full out-of-pocket maximum in a single afternoon, and she wanted a level well above it.

The fall

On a Saturday in June, Marcy and a friend trailered their horses to a canyon trailhead for a morning ride. A mile in, a deer broke out of the brush and Marcy’s horse spun and bolted. She was thrown onto the rocky edge of the trail.

She landed on her left shoulder and hit her head. She was confused for a minute or two and could not lift her arm. Her friend called 911 and walked both horses back while an ambulance crew met Marcy at the trailhead.

At the emergency room, CT scans and X-rays showed a broken collarbone and two broken ribs. The doctor diagnosed a concussion and kept her overnight to watch her. On day 4, a surgeon fixed the collarbone with a plate, under anesthesia, as an outpatient. She went home with prescriptions and saw the surgeon on day 12 and day 27, and again at ten weeks.

Matching her care to the time limits

Her ER visit and the concussion diagnosis were the same day, inside 48 hours. The ambulance, imaging, the overnight stay, the surgery, anesthesia, prescriptions and both follow-ups were all within 30 days. She did not need the extra “as soon as reasonably possible” language Utah has for the 48-hour items, but it is there.

The claim

The policy requires notice of claim within 30 days of the date the loss began, or as soon as reasonably possible. Tom gave notice the following week. Marcy sent the claim form with the EOBs from her health plan. The actual charges after its adjustments:

• Ambulance: $1,700
• Emergency room visit, including the concussion diagnosis: $2,300
• CT scans and X-rays: $2,050
• Overnight hospital stay: $3,100
• Surgery: $7,900
• Anesthesia: $1,300
• Prescriptions: $65
• Two follow-up visits at $170 each: $340

Total actual charges after adjustments: $18,755.

The arithmetic

Step 1. Start with the actual charges: $18,755.

Step 2. Subtract the $250 deductible: $18,755 minus $250 is $18,505.

Step 3. Check the maximum. Marcy’s benefit is up to $20,000 for the calendar year. $18,505 is under that, so the full amount is payable.

Accident ExpenseGuard paid $18,505, directly to Marcy.

She had $1,495 of injury benefit left for the rest of the year ($20,000 minus $18,505). Tom still had his full $20,000. Neither AD&D amount was touched, because a broken collarbone is not one of the losses the AD&D benefit covers.

Putting it against her deductible

On her health plan, the same $18,755 worked out like this:

• Her deductible: $6,000
• 20% coinsurance on the remaining $12,755: $2,551
• That adds up to $8,551, a little more than her $8,500 out-of-pocket maximum.
• What she owed: $8,500, the maximum.

Accident ExpenseGuard covered the $8,500 and left her $10,005. She missed three weeks of work beyond her paid sick days, and a neighbor’s daughter fed and turned out the horses until she could. The rest went into savings.

What the plan did not pay

Paid riding and rodeo. Marcy rides for fun, which the brochure does not exclude. The policy does exclude an injury sustained while paid to participate or instruct in horseback riding, and an injury while taking part in rodeo sports. If she had been hurt while giving a paid riding lesson, or while competing in a rodeo, this plan would not have paid.

Infections. The policy excludes infections of any kind, regardless of how they were contracted. Her incision healed cleanly, but treatment for an infection would not have been covered.

Care after 30 days. As the brochure lists it, doctor visits are covered within 30 days of the accident. Her surgeon’s check at ten weeks fell outside that.

Equipment. The policy excludes durable medical equipment.

Illness. If a stroke had caused the fall, the policy’s exclusion for any cerebrovascular accident would apply.

Example two: a ski crash above Sandy

Kayla is 31, single, and manages the front office of a dental practice in Sandy. Her health plan through work has a $7,500 deductible, then 20% coinsurance up to a $9,400 out-of-pocket maximum. She skis most winter weekends in the canyons above town.

She chose Accident ExpenseGuard at the $10,000 level, covering only herself. Her reasoning was that a single bad fall could use up her whole deductible, and she wanted a level above it.

The crash

On a Saturday afternoon in January, Kayla caught an edge on a groomed run and fell with her right arm out. Her shoulder popped out of its socket.

Ski patrol brought her down to the clinic at the base of the resort, an urgent care center, where a doctor took X-rays and put the shoulder back in place within the hour. An MRI on day 6 showed the shoulder joint had torn. She saw an orthopedic surgeon on day 8, had surgery to repair the joint at an outpatient surgery center on day 22, under anesthesia, and saw the surgeon again on day 29. She filled one prescription for pain medicine.

Matching her care to the time limits

The urgent care visit was the same afternoon, well within 48 hours. The X-rays, MRI, both surgeon visits, the surgery, the anesthesia and the prescription all fell within 30 days.

Her later follow-ups, at six and twelve weeks, did not. As the brochure lists it, doctor visits are covered within 30 days of the accident.

The claim

Her EOBs showed these actual charges after her health plan’s adjustments:

• Urgent care visit, including putting the shoulder back: $380
• X-rays: $150
• MRI: $1,100
• Two surgeon visits at $210 each: $420
• Surgery: $6,400
• Anesthesia: $1,250
• Prescription: $60

Total actual charges after adjustments: $9,760.

The arithmetic

Step 1. Start with the actual charges: $9,760.

Step 2. Subtract the $250 deductible: $9,760 minus $250 is $9,510.

Step 3. Check the maximum. Kayla’s benefit is up to $10,000 for the calendar year. $9,510 is under that.

Accident ExpenseGuard paid $9,510, directly to Kayla.

She had $490 of benefit left for the year ($10,000 minus $9,510).

Putting it against her deductible

On her health plan, the same $9,760 in charges worked out like this:

• Her deductible: $7,500
• 20% coinsurance on the remaining $2,260: $452
• What she owed: $7,952, under her $9,400 out-of-pocket maximum.

Accident ExpenseGuard paid $9,510, which covered the $7,952 and left her $1,558. She put it toward the later follow-up visits and the week she took off work after surgery.

What the plan did not pay

Her later follow-ups. The visits at six and twelve weeks were outside the 30-day window.

Her physical therapy. Physical therapy is not on the brochure’s list of covered services. That list is described as some of the services covered, not all of them, so Kayla asked how the policy treats it rather than assume either way.

Equipment. The policy excludes durable medical equipment, so she did not count on the plan for her sling or the cold-therapy machine she rented.

Paid skiing. Kayla skis for fun, which the brochure does not exclude. The policy does exclude an injury sustained while paid to participate or instruct in skiing. If she worked weekends as a ski instructor and had been hurt teaching a class, this plan would not have paid.

Matching a benefit level to your own deductible

Both women chose a level above what they could owe under their health plans, and in both cases the claim fit under the level.

When the charges are smaller than your level, the plan pays them back minus $250, whatever your health plan does with them. Kayla’s $9,760 in charges came back as $9,510. A $20,000 level would have paid her exactly the same.

When the charges are larger than your level, your level sets the payment. If Marcy had chosen $7,500, the plan would have paid $7,500, and she would have been $1,000 short of her $8,500 out-of-pocket maximum. At $10,000, it would have covered the maximum with $1,500 left. Her $20,000 level covered it with $10,005 left, which mattered because she also lost three weeks of pay.

A few questions to ask yourself:

What is your deductible, and what is your out-of-pocket maximum? Those two numbers are the place to start: your plan’s out-of-pocket maximum is the most it says you pay for covered care in a year. Compare them with the levels: $5,000, $7,500, $10,000, $15,000 or $20,000.

Who is covered? Each covered person has their own yearly maximum and their own $250 deductible, with no more than two deductibles per family in a calendar year. Adding a spouse or children costs extra premium.

What else would an accident cost you? The money is paid to you, so it can go to lost pay, help at home or anything else.

What does a higher level cost? The level is one of the factors in your premium. In a year with no accident, you use none of it.

Can you apply, and for how long? The primary insured and spouse must be 18 to 64 at the time of application. The policy is renewable until the primary insured’s 70th birthday, subject to its terms. The policy says premiums will not change solely because of claims made by a covered person or a change in a covered person’s health.

Is it a substitute for health insurance? No. Accident ExpenseGuard is a supplement. It is not major medical coverage, it is not Minimum Essential Coverage, and it does not pay for illness. It also does not cover an injury arising out of, or in the course of, employment for wage or profit. Marcy and Kayla both kept their health plans, which still paid their share of each bill.

The short version

After Marcy’s fall from her horse near Logan, Accident ExpenseGuard paid her $18,505, which covered her $8,500 out-of-pocket maximum with $10,005 left for lost pay and help at home. After Kayla’s ski crash above Sandy, it paid $9,510 against the $7,952 she owed. Neither payment covered equipment or care past 30 days, and the plan would not have paid at all for riding or skiing done for pay.

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