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Old 02-16-2017, 02:44 PM   #1
CinderAbby
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I'm confused regarding insurance's deductibles and maximum out of pocket payments

I admit it - I'm highly, highly spoiled when it comes to insurance. The plan I have through school, although extremely pricey, covers absolutely everything either 100% or as copays. There are no deductibles, coinsurance amounts or out of pocket maximums to deal with.

Really long story short, I'm confused when it comes to insurance offered nowadays. The plan Lenny is offered through Home Depot has all three of the above mentioned and with his health problems, it's concerning to me what it could potentially cost if he's admitted again (knock on wood he's not).

For this particular plan, the deductible is 750/2250 and the OOP max is 5000/10000. So how does this work exactly? Most of our medical expenses are for Lenny. So does this mean that for anything for him all we would have to pay is the $5000 and then everything after that would be covered? Or does it mean the insurance company would make us pay $10000 since it's a family plan (this is what I keep thinking)?

Anyone with experience with this kind of plan that can shed some light on it for me would be greatly appreciated. I just don't know if I'm thinking of it correctly (we'd have to pay the 10000 just for Lenny because it's a family plan) or I'm incorrectly thinking family when that's not the case.
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Old 02-16-2017, 03:21 PM   #2
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Can he choose just to insure himself? Then you could get insurance for you and Abby somewhere else? I ask because I think that if it's a family plan, you need to hit the family deductible amount even if all the expenses are for one member of the family.

Insurance is so confusing. I wish I could help more. I leave the insurance matters up to my DH, and I just write the checks when the bills come in.
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Old 02-16-2017, 03:29 PM   #3
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If you are only insuring Lenny it would be the 750 and 5000. If you and Abby are covered then it is a family plan and would be the higher numbers 2250/10000.


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Old 02-16-2017, 03:33 PM   #4
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With my insurance we have a $250 deductible person or $500 deductible for the family. Basically if one of us uses up their $250 deductible any more expenses would be covered at 80% without more going to the $500 family deductible. The remaining $250 could be used by one person or split between the other two of us. The same is true for our OOP expenses (I just can't remember the amounts right now).

Make sense or did I confuse you?
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Old 02-16-2017, 08:15 PM   #5
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Quote:
Originally Posted by CinderAbby View Post
I admit it - I'm highly, highly spoiled when it comes to insurance. The plan I have through school, although extremely pricey, covers absolutely everything either 100% or as copays. There are no deductibles, coinsurance amounts or out of pocket maximums to deal with.

Really long story short, I'm confused when it comes to insurance offered nowadays. The plan Lenny is offered through Home Depot has all three of the above mentioned and with his health problems, it's concerning to me what it could potentially cost if he's admitted again (knock on wood he's not).

For this particular plan, the deductible is 750/2250 and the OOP max is 5000/10000. So how does this work exactly? Most of our medical expenses are for Lenny. So does this mean that for anything for him all we would have to pay is the $5000 and then everything after that would be covered? Or does it mean the insurance company would make us pay $10000 since it's a family plan (this is what I keep thinking)?

Anyone with experience with this kind of plan that can shed some light on it for me would be greatly appreciated. I just don't know if I'm thinking of it correctly (we'd have to pay the 10000 just for Lenny because it's a family plan) or I'm incorrectly thinking family when that's not the case.
I am an Insurance Specialist and I hope I can be of some help to you on this matter. Without calling your insurance company and verifying directly with them, I feel I can help make some sense of your policy.

The policy has an individual deductible of $750/family deductible of $2,250. Most plans generally are comprehensive meaning that when the individual deductible of $750 is met for Lenny, then he will pay a co-insuance percentage, until he reaches his individual out of pocket of $5.000. After he has paid $5.000, he will pay nothing for the remaining of the year. This will also be the same for you and Abby. Once each of you have met your individual deductible of $750, you'll pay your coinsurance amount also. The family out of pocket amount can be met by only one or all of you all together. For example, if Lenny possibly had a hospitalization with a total balance due after insurance paid of $10,000 or more, then he has met it for the whole family. What I can't be for certain of is if the deductible amount paid applies to your out of pocket or not. I would have to see how your claims pay before I know that to be the case. Some plans include that amount paid as part of your out of pocket and others don't.

I hope that some of what I've shared with you is helpful.
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Old 02-17-2017, 06:50 AM   #6
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I am not in the insurance business but I do use insurance on a regular basis. I have some of the same issues as Lenny. My understanding is and my policies have paid exactly as Mimidodapigi says.

You can call the insurance company or the HR dept if through employment.

I have my insurance through the exchange and some out of pocket expenses count towards the deductible, others do not. It is a pain to figure out. And remember a year is the plan year, usually January to January so if you join in March, your deductible year is 10, not 12 months.
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Old 02-17-2017, 09:13 AM   #7
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Definitely call the insurance coordinator. All insurance is different even through the same company.
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Old 02-17-2017, 12:09 PM   #8
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Quote:
Originally Posted by jenifermg0 View Post
With my insurance we have a $250 deductible person or $500 deductible for the family. Basically if one of us uses up their $250 deductible any more expenses would be covered at 80% without more going to the $500 family deductible. The remaining $250 could be used by one person or split between the other two of us. The same is true for our OOP expenses (I just can't remember the amounts right now).

Make sense or did I confuse you?
WOW! This is a fantastic plan. We used to have one similar, but over the last 2 or 3 years it's has really gone up.
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Old 02-17-2017, 02:34 PM   #9
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WOW! This is a fantastic plan. We used to have one similar, but over the last 2 or 3 years it's has really gone up.
No kidding!! I work for the State of Alaska and have for almost 28 years. When I started we had a $100 deductible!!!

I expect our plan to start changing for the worse in the not so distant future, but I'll be grateful for what I have now.
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Old 02-18-2017, 03:52 AM   #10
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Sadly I learned all I ever wanted to know about insurance last October when my Dh fell off of our roof and was in the hospital with two brain bleeds for several days. (he's doing remarkably well now, thankfully!)

The deductible comes into play anytime you're in the hospital, getting things like MRI or CT, some lab work, etc. The OOP is the maximum you will pay out of pocket for that year. Once you reach that, everything is covered 100%. No more copays, prescription costs, etc-for that year. It starts over the next year though.

So I'm reading this as each person has a $750 deductible, with the most your family will pay for a deductible at $2250. (The benefit here would be for a 4+ person family, as that's when they give somewhat of a discount on the deductible after that.)

Heaven forbid that Lenny is admitted to the hospital. He'll have to pay that $750 deductible, and then he'll pay a percentage of the rest of the bill, depending on what the policy states, (ours is we pay 20%) until he reaches $5000, your OOP max. He could easily reach that OOP max from one hospital stay. Then, he's golden for the rest of the year.

The $10,000 OOP max comes into play if two of you were to have a medical crisis-surgery, hospital stay, etc. The same thing would happen-you'd meet your deductible, pay a percentage of the bill until you each reached $5,000, then everyone's medical would be 100% covered for the rest of that calendar year.

Last year, dh met his OOP Max of $6000 from just a 3 day stay in the neuro ICU. His total bill was a bit over $20,000. The nice thing was that after that, he didn't have to pay copays, for prescriptions, etc. sadly, that was all at the end of the year so we didn't see a huge benefit, but every little bit helps.

Hope I didn't confuse you even more!
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Old 02-18-2017, 07:51 AM   #11
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Lenny, then he will pay a co-insuance percentage, until he reaches his individual out of pocket of $5.000. After he has paid $5.000, he will pay nothing for the remaining of the year.
Quote:
For example, if Lenny possibly had a hospitalization with a total balance due after insurance paid of $10,000 or more, then he has met it for the whole family.
Your second sentence contradicts the first.


Quote:
Hope I didn't confuse you even more!
No you didn't. That was actually what I was looking for - actual experience although I didn't expect it to be quite that bad of an example. I'm sorry to hear your hubby fell off the roof but I'm happy to hear he's doing well.
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Old 02-18-2017, 08:43 AM   #12
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Darlene,

I have not had a family plan for four years and when I did just about everything was paid (group insurance with top company), As an individual, I have had to meet both my deductible and my out of pocket max. For me understanding what each of these were was easy. My deductible was $1500., out of pocket max was $2500.

The hard part, I found, was knowing what would count towards these two. I was also shocked by things that were not covered. I know you are not doing the ACA but policies tend to pay for preventative services (well child stuff, annual physical) and not things with a diagnosis. My plan would not pay for a follow up with my PCP although she is in the plan and it is advertised as an HMO.

That said, I don't know if you can reasonable plan on the most you will have to pay. I did meet my out of pocket maximum on the group insurance after which everything was covered 100%.

One thing that you may want to look at is lists of preferred drugs if you plan to use a drug store. Companies negotiate prices and even if they don't pay, you get the negotiated price. Your doctor's office can also usually prescribe off the preferred list. I went to pick up one drug and it was $400+ a month. My doctor's office changed it to a covered prescription and while I had to pay the copay, it was reasonable.

Also I went from a copay per script to a percentage and the percentages are actually less.

Insurance is a confusing mess. I think policies are written that way so people don't always know what they are buying.
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Old 02-18-2017, 09:31 AM   #13
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Insurance is a confusing mess. I think policies are written that way so people don't always know what they are buying.
I totally agree with this.
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Old 02-18-2017, 04:50 PM   #14
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Darlene,

I found help at our local hospital. When I had my hospital stay in 2013, they sent someone to help me figure out my insurance costs and out of pocket expenses. If you can't get answers from your insurance company, maybe there's someone at the hospital that would help you. It might be worth a check.
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Old 02-20-2017, 12:38 PM   #15
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Lenny, then he will pay a co-insuance percentage, until he reaches his individual out of pocket of $5.000. After he has paid $5.000, he will pay nothing for the remaining of the year.
Quote:
For example, if Lenny possibly had a hospitalization with a total balance due after insurance paid of $10,000 or more, then he has met it for the whole family.

Your second sentence contradicts the first. "quoted by Cinder Abby"

Not quite, CinderAbby. What she is saying is that - If Lenny hits the $5000 personal maximum, HE will pay nothing else for the rest of the year. If Lenny hits the $10000 family maximum, YOUR ENTIRE FAMILY pays nothing else for the rest of the year.

I am not sure, though, if this is how it works. We have VERY good insurance through DH's job and have no deductibles and no co-insurance but are limited to plan doctors and other plan-specific places, including pharmacies (which we do have a co-pay on prescriptions with no maximum limit).
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