health insurance question

[livingalmostlarge]

Most of you are way more savvy in understanding health insurance so I might as well ask. Maybe even some work in this field.

So we have a regular PPO plan. No HDHP and no hsa. Our deductible per person is $200/year. Our maximum family deductible is $600. Our maximum out of pocket per person is $1500 and $4500 per family per year.

So how does it work with co-pays and percentages. We pay our copays no matter what? Do co-pays stop after we hit $1500? Do % stop after $1500?

What happens when you have multiple bills being processed all at the same time?

My basic understanding is once we pay $4500 for the year we are done? No more copays? Or am i wrong?

Do I pay bills as they come in or wait and see what else is being processed and when? How do you guys handle it?

 

[MichaelB]

It is indeed complicated.

Once one family member has paid $1500 between deductible and copay, the insurance pays for 100% of covered expenses from then on for that person. Once the entire family has paid $4500 in deductible and copay, insurance pays 100% of all new covered expenses. Then on Jan 1 it resets and you start again.

They deductible of $200 per year means you pay the first $200, then insurance starts to pay. In all cases, you pay copay or coinsurance for each event until you meet your total out of pocket for the year.

For each provider service you receive, the insurer will send you an EOB, explanation of benefits, breaking down the bill and telling you how they will pay and how much you need to pay. In the case of multiple bills, you should wait until you get the EOB. If you are close to the max out of pocket your health care provider will probably charge you the copay and then the EOB will indicate you should not have paid. You will then need to go back to the provider and ask for money back.

 

[zl55lz]

Most of you are way more savvy in understanding health insurance so I might as well ask. Maybe even some work in this field.

So we have a regular PPO plan. No HDHP and no hsa. Our deductible per person is $200/year. Our maximum family deductible is $600. Our maximum out of pocket per person is $1500 and $4500 per family per year.

So how does it work with co-pays and percentages. We pay our copays no matter what? Do co-pays stop after we hit $1500? Do % stop after $1500?

What happens when you have multiple bills being processed all at the same time?

My basic understanding is once we pay $4500 for the year we are done? No more copays? Or am i wrong?

Do I pay bills as they come in or wait and see what else is being processed and when? How do you guys handle it?

MichaelB gave a nice overview. It is difficult to answer in-depth with such limited info, e.g., still employed, retired with Medicare, Medicare Advantage Plan, etc? My opinion is to get the Plan brochure and read it thoroughly for your situation to become familiar with options and situations. The Plan should also have a contact number to call to ask specific questions for your situation. Sometimes they have a "chat" option to ask questions and get responses. In my extensive experience with Plans of various types there seems to be different answers for different situations.

 

[Dash man]

There are some plans that will always require a copay, but no coinsurance after the out of pocket limit is met. Other plans don’t have copays, but do have coinsurance. Read the documents carefully and there should be examples of how it works. I’ve had many different kinds of plans, as I’m sure many here have.