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No, the $4000 for both your deductible and OOP is not uncommon with a tax qualified high deductible plan so it probably is correct but it doesn't hurt to double check.
In your case a MEC plan would not be a good idea. For someone that is healthy and never goes to the dr, it might be, but it's still short sighted I think.
Do you have coverage now in October from your previous job? I was adding back to September with my numbers above since that is when you were laid off.
That $4k OOP plan is from Colorado Health OP which is in the news that it's shutting down so that won't work.
Not sure why it's even a choice now.
The only other plan with small OOP is the Humana HMO:
It also has $500 or something on the prescription drug deductible but nothing else.
I assume Annual Max Costs is the same as OOP. :confused:
Interestingly, that plan is not available when I go directly at Humana site.
Do you think this HMOX plan is better option for me?
Thank you in advance.
I'll call and find out if it's annual deductible is for one year after I start my coverage or just till year end.
Here is the plan details:
Quote:
HUMANA HEALTH PLAN, INC:
Humana Platinum 1000/Colorado HMOx Coverage Period: Beginning on or after 01/01/2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: HMO
Cost Sharing Benefits
Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.
Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $1,000 Data Not Available
Deductible (Family) $2,000 Data Not Available
Coinsurance 20% Data Not Available
Out of Pocket Maximum (Individual) $1,500 Data Not Available
Out of Pocket Maximum (Family) $3,000 Data Not Available
Services In Network Out of Network
Primary Care Visit $25 Data Not Available
Specialist Visit $35 Data Not Available
In Patient Hospital Services 20% Coinsurance after deductible Data Not Available
Emergency Room Services 20% Coinsurance after deductible 20% coinsurance
Mental / Behavioral Health 20% coinsurance Data Not Available
Imaging (CT/PET Scans, MRIs) 20% coinsurance Data Not Available
Rehabilitative Speech Therapy 20% coinsurance Data Not Available
Rehabilitative Occupational & Physical Therapy 20% coinsurance Data Not Available
Preventative Care $0 Data Not Available
Laboratory Outpatient and Professional Services 20% coinsurance Data Not Available
X-ray and Diagnostic Imaging 20% coinsurance Data Not Available
Outpatient Facility 20% coinsurance Data Not Available
Outpatient Surgery 20% coinsurance Data Not Available
Prescription Drugs In Network Out of Network
Generic Rx $8
Preferred Brand Rx $20 Copay after deductible
Non Preferred Brand Rx 35% Coinsurance after deductible
Specialty Drugs 35% Coinsurance after deductible
- See more at: Humana Humana Connect Platinum 1000/1500 Plan GA
I'm not much of a fan of HMO's personally, but if your doctors are in that network and you never travel, it will be ok in the short term. I would ask about the out of pocket costs as well if it is calendar year or plan year, yes, the annual max is the same as out of pocket max. Just realize that if you go with an HMO and any doctor you see it out of network, you will pay 100% of that bill and it won't count toward any out of pocket costs. Call the OB specifically and the hospital where you will have your baby and check, double check and triple check that they are in THAT NETWORK, not just "do you take Humana" but "are you in the Humana Humana Platinum 1000/Colorado HMOx network". Then call Humana and have them verify that your doctors and hospital are in that network, not just in A Humana network.
I'm not much of a fan of HMO's personally, but if your doctors are in that network and you never travel, it will be ok in the short term. I would ask about the out of pocket costs as well if it is calendar year or plan year, yes, the annual max is the same as out of pocket max. Just realize that if you go with an HMO and any doctor you see it out of network, you will pay 100% of that bill and it won't count toward any out of pocket costs. Call the OB specifically and the hospital where you will have your baby and check, double check and triple check that they are in THAT NETWORK, not just "do you take Humana" but "are you in the Humana Humana Platinum 1000/Colorado HMOx network". Then call Humana and have them verify that your doctors and hospital are in that network, not just in A Humana network.
Building on Querty's point, don't assume that because the hospital and your OB are in the network (if they are) that you're home free. Ask the OB about the anesthesiologist, in case the baby has to be delivered by cesarian. In my area, increasingly different departments within the hospital are, effectively, separate entities.
In the old days, if the hospital accepted the plan, all employees and services were covered. Now you might find out the anesthesiologist is not an employee of the XYZ hospital but of "XYZ Anesthesology Group." If that group isn't in the network, you'll pay 100% of the anesthesiology out of your own pocket. I don't know that much about the possible other professionals that could be involved if (God forbid) you have last minute labor complications. And don't assume that your doctor knows about these distinctions. I've met doctors who literally said to my face "Oh, I don't know anything about health insurance, my business manager runs all that, all I want is to provide patient care." If I were you I'd start with a rundown of the people or services that might be needed if there are complications (what about Neonatal ICU?, etc.) then ask for an appointment with the billing supervisor at the hospital to go over your list and see if those services are in the same network. Make sure to say "Are in the ABC health insurance HMO "Freedom Now Gold Multichoice plan" or whatever the coverage is actually named. Some insurance companies have entirely different networks for each of their different plans. Others have one network for direct pay policies, and a separate network (or set of networks) for employer-provided plans.
Building on Querty's point, don't assume that because the hospital and your OB are in the network (if they are) that you're home free. Ask the OB about the anesthesiologist, in case the baby has to be delivered by cesarian. In my area, increasingly different departments within the hospital are, effectively, separate entities.
In the old days, if the hospital accepted the plan, all employees and services were covered. Now you might find out the anesthesiologist is not an employee of the XYZ hospital but of "XYZ Anesthesology Group." If that group isn't in the network, you'll pay 100% of the anesthesiology out of your own pocket. I don't know that much about the possible other professionals that could be involved if (God forbid) you have last minute labor complications. And don't assume that your doctor knows about these distinctions. I've met doctors who literally said to my face "Oh, I don't know anything about health insurance, my business manager runs all that, all I want is to provide patient care." If I were you I'd start with a rundown of the people or services that might be needed if there are complications (what about Neonatal ICU?, etc.) then ask for an appointment with the billing supervisor at the hospital to go over your list and see if those services are in the same network. Make sure to say "Are in the ABC health insurance HMO "Freedom Now Gold Multichoice plan" or whatever the coverage is actually named. Some insurance companies have entirely different networks for each of their different plans. Others have one network for direct pay policies, and a separate network (or set of networks) for employer-provided plans.
That has never been true. Insurance companies contract both with the doctors and facilities. If the doctor is an actual employee of the hospital, yes, they will be in-network under the hospital contract, however, most doctors only have privileges at hospitals, including anesthesiologists, and will contract individually with an insurance company, so you are correct, you need to check any and all providers you may come in contact with. Think of the doctors and independent contractors if you will. You CAN request an anesthesiologist in advance. The only exception to this, thanks to the ACA, is if it is a true emergency, life threatening, all care must be billed in network.
Why the hell is insurance so complicated?
No wonder they can't collect all the bills.
Nothing can compare to Kaiser in that regard as the whole hospital is Kaiser including everyone who works there but that's not an option for now, at least not if I can avoid it.
Will try to get hold of them (humana) today and check networks.
Thanks
Read the plan details and the calendar year is what it is.
Quote:
Important to know:
› If your family is covered, your individual deductible and out-of-pocket
accumulate to the individual and the family maximum. An individual
covered family member will receive coinsurance benefits once they have
met their individual deductible. The rest of the covered family members
will receive coinsurance benefits once they have satisfied their individual
deductible, or when the entire family deductible has been satisfied
› Once you reach your out-of-pocket maximum, then this plan will pay 100%
of all covered expenses
› Copays do not accumulate toward the deductible, but they do accumulate
to the out-of-pocket maximum
› Deductibles and out-of-pocket maximum start over each new calendar year
One thing I am confused in this plan is if only one member has medical bills, does it still go to full family OOP or it's limited to individual OOP of $1500?
The first bullet indicates the family plan has an "embedded" individual deductible and OOP max for each covered member. Therefore, if only one member has medical bills the policy will start paying 80% (you have 20% coinsurance) once the individual deductible is met and will pay 100% once the individual OOP max has been met. These amounts are also applied to the family limits for when another member receives medical care.
Looks like I have to apply for coverage at connectforhealth colorado.
Can't just buy it without their approval after application.
I checked doctors and few who my wife went last time are in that network.
Couldn't find if the hospital near us is in network so I'll do more searching.
Quote:
Originally Posted by SCGamecock
The first bullet indicates the family plan has an "embedded" individual deductible and OOP max for each covered member. Therefore, if only one member has medical bills the policy will start paying 80% (you have 20% coinsurance) once the individual deductible is met and will pay 100% once the individual OOP max has been met. These amounts are also applied to the family limits for when another member receives medical care.
So that means if only my wife has medical bills this year, OOP would be $1500 even if family OOP is $3000.
That's better even if the OOP resets starting in January for next year.
Read the plan details and the calendar year is what it is.
One thing I am confused in this plan is if only one member has medical bills, does it still go to full family OOP or it's limited to individual OOP of $1500?
You have an individual and a family deductible. When your wife goes into the hospital, her responsibility for the bills will top out at the individual out of pocket max ($2000). If you were also to be hospitalized, say you needed your gallbladder out, you would be responsible for bills for $500 for your deductible and another $500 for co-insurance based on those numbers.
You will pay the first $1000 of the bills, then 20% of the rest of the bills until you have written checks for $2000. If a second person on the plan has medical expenses, you pay the first $500 of those, then 20% until you have written checks for another $500 (so $3000 total as a family).
Quote:
Originally Posted by Mystery123
Why the hell is insurance so complicated?
No wonder they can't collect all the bills.
Nothing can compare to Kaiser in that regard as the whole hospital is Kaiser including everyone who works there but that's not an option for now, at least not if I can avoid it.
Will try to get hold of them (humana) today and check networks.
Thanks
Kaiser is an HMO and as long as you go to a Kaiser facility, yes, that is how it would work. However, if you go to a non-Kaiser facility, you pay 100% of everything unless it was a true emergency.
Quote:
Originally Posted by Mystery123
Looks like I have to apply for coverage at connectforhealth colorado.
Can't just buy it without their approval after application.
I checked doctors and few who my wife went last time are in that network.
Couldn't find if the hospital near us is in network so I'll do more searching.
So that means if only my wife has medical bills this year, OOP would be $1500 even if family OOP is $3000.
That's better even if the OOP resets starting in January for next year.
Ask if there is a 4th quarter roll-over though. Some plans have that, meaning if you meet your OOP in the 4th quarter, you don't have to meet the OOP costs again the following year.
You have an individual and a family deductible. When your wife goes into the hospital, her responsibility for the bills will top out at the individual out of pocket max ($2000). If you were also to be hospitalized, say you needed your gallbladder out, you would be responsible for bills for $500 for your deductible and another $500 for co-insurance based on those numbers.
You will pay the first $1000 of the bills, then 20% of the rest of the bills until you have written checks for $2000. If a second person on the plan has medical expenses, you pay the first $500 of those, then 20% until you have written checks for another $500 (so $3000 total as a family).
If we're still talking about the Humana Platinum 1000 plan from the above post, the embedded individual OOP max within the family plan should be $1500. If only one member has medical bills, that member will write checks until $1500 has been paid.
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