Anyone knowledgable in health insurance, please help me out. We have been offered an 80-20 PPO insurance plan by my husbands employer. It states the office co-pay is $20, the CY (calendar year I assume) family deductible is $500, and the family maximum co-insurance is $1500. Question #1) does this mean if my whole family is treated in the ER, we owe the $500 deductible plus coinsurance up to $1500 for a maximum out of pocket expense of $2000 in a year? Obviously an ER bill for 4 people would be atrociously expensive. Am I understanding correctly that we would owe no more than $2000 that year? Even if we had follow up office care we would only owe our co-pay, no further deductible or co-insurance? Question #2) How is the billing done? Do we pay cash all year until we meet the family deductible of $500, and then we owe 20% of each bill thereafter up to a maximum of $1500? Then the insurance is supposed to pay 100% after that? Am I understanding properly or am I missing something? Thanks ladies!
Your deductible is 500 so everything before 500 is out of pocket everything above that is subject to a percent co-insurance until that reaches 1,500. So the max out of pocket is 2,000 unless they do not consider office co-pays as part of the co-insurance.
It looks like you have a pretty good handle on what you have, better than most I must say. :)
Wow. This sounds like a great plan....depending on what you are paying in premiums each month. If you are looking at this plan and another, you need to figure out the maximum amount you would pay in a calendar year for each. That would be maximum out of pocket for your family each year plus your premiums each month for a year.
*You pay $20 for each co-pay for each regular office visit (if there is one...some well-child, annual visits are free).
*You will probably pay up to $100 co-pay for emergency room and/or ambulance rides.
*You will always pay a co-pay even if you meet your deductible.
*Once you hit your decuctible per person ($500), you pay 20% of the bill up to your maximum (per person) out of pocket price. This out of pocket price does not include your deductible. So if your maximum out of pocket is $1500 (which you are not clear about), you would pay $2000 in the end. Then insurance covers the remaining visits (except co-pays), surgeries, etc. at 100%.
*This is the same per person in your family.....but then there is a FAMILY maximum out of pocket amount (usually around $5000). If each person in the family was $1500 (not including the per person or family deductible), and you had 4 people in your family then it would seem like it would be 4 X $1500 = $6000, but most ins. policies cap it for less....like $5000. And if you had 6 people in your family, it would still be the less capped price of $5000 (if this is the amount in your policy).
Let me know if I wasn't clear. :)
Again, compare using the price of your premiums each month and how often you go to the doctor, and what your family's health is like. It is always a gamble to guess what coverage that best fits your needs for the price you can afford.
It depends, of course! In PPO's, normal office visits can be subject or non-subject to deductible. I have seen both. It sounds like, with the $20 co-pay, you are not subject to deductible. These plans are still out there but are not common. I would ask for clarification.
The 2nd question you need to ask is what is your out of pocket maximum? Co-insurance and out-of-pocket could have different definitions in your employers plan document. If it is $1500, that means that you are subject to $500 max expense per person, and once you hit $1500 total out of pocket everything is covered after that. That $500/per/person is going to be comprised of things like lab expense, specialist vists, and the 20% you are responsible for after deductible.
Because you do have that 20% responsibility, i'm a bit suspicious that your max out of pocket is $1500 for the entire family. Normally that 20% drags on to a much higher liability point.
I guess my bottom line is no one can be certain based upon what you've presented here. Don't be afraid to call and ask detailed questions. HR teams exist to answer questions just like this.
p.s. Sounds like a pretty good plan to me!
I also have a PPO with the same terms - higher deductibles unfortunately. I believe you are correct at least that's how I understand it. I'll review your responses to be sure I'm right. If not, I may have to re-think our insurance!
I have a similar plan but my prescriptions are only covered if they're generic. It was clearly stated GENRX plan. Your out of pocket max (if that's what's meant by coinsurance??) sounds too low. Is it $1500 per person? If it is a family max you have a great plan!!!
