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Ignorant question about health insurance deductibles and out of pocket maximums
Posted on 9/25/14 at 12:07 pm
Posted on 9/25/14 at 12:07 pm
Please don't bash me too bad, I've always had a zero deductible health insurance plan with upfront co-pays for everything. I'm now having to switch to a plan with a $500 deductible and $3000 OOP maximum. The smaller details include something like for ER visits "100% coverage subject to deductible"...everything else sort of reads like that and includes 100% coverage after deductible except of course PCP or specialty visits which have upfront co-pays.
My question:
Does this work like homeowners insurance? Meaning, every time there is a major occurrence(ER trip, surgery, whatever...) within a calendar year I have to reach the $500 deductible each time up until I hit $3000?
Or do I only have to hit $500 once in a calendar year and then it is 100% coverage on everything else? If this is the case I'm confused about the OOP maximum.
My question:
Does this work like homeowners insurance? Meaning, every time there is a major occurrence(ER trip, surgery, whatever...) within a calendar year I have to reach the $500 deductible each time up until I hit $3000?
Or do I only have to hit $500 once in a calendar year and then it is 100% coverage on everything else? If this is the case I'm confused about the OOP maximum.
7
Posted on 9/25/14 at 12:15 pm to LSUsmartass
Interested in these answers too
Health insurance confuses the shite out of me
But I'm almost certain you only have to hit your deductible once
The OOP max comes in when you have coverage that may be only 50% after deductible, meaning you still owe 50% even though you've met your deductible
Health insurance confuses the shite out of me
But I'm almost certain you only have to hit your deductible once
The OOP max comes in when you have coverage that may be only 50% after deductible, meaning you still owe 50% even though you've met your deductible
This post was edited on 9/25/14 at 12:17 pm
Posted on 9/25/14 at 12:22 pm to Croacka
quote:
The OOP max comes in when you have coverage that may be only 50% after deductible, meaning you still owe 50% even though you've met your deductible
This is what confuses me, the plan I am looking at has 100% coverage of everything after deductible is met, but still lists a $3000 OOP max.
Posted on 9/25/14 at 12:24 pm to LSUsmartass
quote:
I only have to hit $500 once in a calendar year
This
Your insurance may have an 80% coverage 20% co insurance amount after the deductible. I think this means that you would pay 20% of the amount of each service until you hit $3000 maximum for the year. Read the policy and see what your co insurance is.
This post was edited on 9/25/14 at 12:25 pm
Posted on 9/25/14 at 12:26 pm to LSUsmartass
quote:
This is what confuses me, the plan I am looking at has 100% coverage of everything after deductible is met, but still lists a $3000 OOP max.
Oh, then I don't know
Posted on 9/25/14 at 12:26 pm to ljd4662
quote:
Your insurance may have an 80% coverage 20% co insurance amount after the deductible. I think this means that you would pay 20% of the amount until you hit $3000 maximum for the year. Read the policy and see what your co insurance is.
Right, it would all make sense if the plan had co-insurance listed or an 80/20 split on some services but everything that doesn't have an upfront co-pay is listed as 100% coverage after deductible is met.
Posted on 9/25/14 at 12:40 pm to LSUsmartass
If that's the case then the $3k max is for out of network, most likely.
Posted on 9/25/14 at 12:50 pm to LSUsmartass
Are you SURE that everything is either co-pay or 100 percent pay after dedctible?
If so... the OOP max may refer to the total of your deductible plus co-pays that are not subject to the deductible. Traditionally, co-pays were not counted as part of the OOP max. But I read a policy a few weeks ago where co-pays WERE included when calculating the OOP max.
If that's the case, then here is how I would understand it:
Co-pays paid each time for things that have co-pays.
Things that don't have a co-pay, you pay the first $500 cumulative for all of these types of things, then all of these types of things are paid by insurer at 100 percent.
Once you have $2,500 in co-pays, then you add that to your $500 paid deductible, and you hit your OOP max. Now, you don't pay co-pays either for rest of year.
If so... the OOP max may refer to the total of your deductible plus co-pays that are not subject to the deductible. Traditionally, co-pays were not counted as part of the OOP max. But I read a policy a few weeks ago where co-pays WERE included when calculating the OOP max.
If that's the case, then here is how I would understand it:
Co-pays paid each time for things that have co-pays.
Things that don't have a co-pay, you pay the first $500 cumulative for all of these types of things, then all of these types of things are paid by insurer at 100 percent.
Once you have $2,500 in co-pays, then you add that to your $500 paid deductible, and you hit your OOP max. Now, you don't pay co-pays either for rest of year.
Posted on 9/25/14 at 1:01 pm to LSUsmartass
Basically out of pocket max means that no matter what happens you only pay up to 3000 in a calendar year. If everything is covered 100% after deductible then you are good and won't ever need that.
Posted on 9/25/14 at 1:46 pm to LSUsmartass
quote:
Or do I only have to hit $500 once in a calendar year
This. You pay the first $500 in each plan year. After that you pay normal co-pays and fees until you reach the $3000 OOP. Then everything is covered 100% for the remainder of the plan year.
Posted on 9/25/14 at 1:48 pm to LSUsmartass
quote:
This is what confuses me, the plan I am looking at has 100% coverage of everything after deductible is met, but still lists a $3000 OOP max.
Don't forget your prescription drugs. They count toward the $3000 and they're not normally covered 100%.
This post was edited on 9/25/14 at 1:49 pm
Posted on 9/25/14 at 3:06 pm to LSUsmartass
You pay deductible once per year. So if you hit it in January, insurance coverage will apply the rest of the year. The OOP max is the most you will pay per year, including deductible. So you will pay first $500, and whatever % your plan specifies up to a maximum of $3,000/year.
FWIW $500 is pretty low. if you're pretty healthy and have anything saved up, you would probably save a lot of money if you bumped it up to a couple thousand. you could always set up hsa to pay expenses tax free. my (family) deductible is a few thousand, although company pays a portion.
FWIW $500 is pretty low. if you're pretty healthy and have anything saved up, you would probably save a lot of money if you bumped it up to a couple thousand. you could always set up hsa to pay expenses tax free. my (family) deductible is a few thousand, although company pays a portion.
This post was edited on 9/25/14 at 3:09 pm
Posted on 9/25/14 at 9:03 pm to LSUsmartass
I don[t know about the specifics of your plan, but the way the high deductible plans are working that most companies are adopting is by calendar year.
On our plan, we have a total family $3,000 deductible. The individual plan deductible is $1500. When we go to the doctor, we are to be charged the price for that service that the insurance company would ordinarily receive. This includes prescriptions. Paid $179 the other day for a script and that was with the insurance discount.
When we reach $3000 out of pocket in a calendar year, we are responsible for 20% of the charges until we have spent out of pocket $10 grand. We have a HSA that we are socking money into and we have been paying the out of pocket medical expenses with the pre tax HSA.
From what you posted, sounds like you have to pay $500 out of pocket, then likely some type of split until you reach $3000. Read your information carefully because in some instances a service is covered 100% and not subject to deductible. For instance, one check up a year etc. Policy should have list of the exceptions.
Seems like more and more companies are adopting these plans. LOTS of loopholes. For instance, on our plan, one check up a year is covered, but IF your physician sends your blood work out, that is not included. You really need to read all the info on your plan.
On our plan, we have a total family $3,000 deductible. The individual plan deductible is $1500. When we go to the doctor, we are to be charged the price for that service that the insurance company would ordinarily receive. This includes prescriptions. Paid $179 the other day for a script and that was with the insurance discount.
When we reach $3000 out of pocket in a calendar year, we are responsible for 20% of the charges until we have spent out of pocket $10 grand. We have a HSA that we are socking money into and we have been paying the out of pocket medical expenses with the pre tax HSA.
From what you posted, sounds like you have to pay $500 out of pocket, then likely some type of split until you reach $3000. Read your information carefully because in some instances a service is covered 100% and not subject to deductible. For instance, one check up a year etc. Policy should have list of the exceptions.
Seems like more and more companies are adopting these plans. LOTS of loopholes. For instance, on our plan, one check up a year is covered, but IF your physician sends your blood work out, that is not included. You really need to read all the info on your plan.
Posted on 9/26/14 at 6:11 am to Blakely Bimbo
The way most High deductible plans work are that if you are in network your deductible is $500, once you meet that you are covered 100%. However for example say you are injured out of state and end up at a hospital that is out of network normally in this case you have a different deductible, or are responsible for 20% (really depends upon your plan). Then once you have hit the $3000 out of network you no longer are on the hook for anything. So if you are in network max out of pocket is $500, if out of network max out of pocket is $3000. Hope that makes sense.
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