s/o Health Insurance - family vs individual OOP max

[ebeth]

Yes. Individual deductibles/OOP max only apply to individual plans.

[rootbeerfloat]

Wasn't mrsspunky good at these kinds of questions?

[jewel]

It's not the answer you're hoping for, LOL.

I had never had a HDHP before our current plan, and I was under the impression that $1500/$3000 meant that any one person would cap at $1500, with the family total max at $3000.

Wrong. The way it's worded in the benefits paperwork is deceiving

ETA - I could be totally wrong about your plan, because I was just thinking HDHP, which may have different rules.

[melsamoony]

Our health plan specifically states that an individual on a family plan cannot exceed the oop max/deductible for an individual.

[Ashley&Scott]

Jul 2, 2015 16:46:11 GMT -5 @starry said:

Please explain this to me. Hypothetically (for the case of example), if you're on a family plan, but all the expenses for the year are attributable to one person, do you still pay the family deductible / OOP max? 

Let's say:

4 people on a family plan
3 people have 0 expenses, last person has $10k expenses

Plan coverage reads individual deductible $1500 / family $3000; individual OOP max - $3000; family $6000.

Is your deductible $1500 or $3000? Same with OOP max.

Does the individual only mean if you are on the individual plan that is what applies? 

It means that for any individual on the plan their deductible is 1500 & that person won't pay more than 3000 per year for their care. Usually this only applies to co-insurance & co pays are excluded from the OOP max. The family amounts mean that you won't pay more than what's listed for any combination of the family members on the plan. So if you're all 4 on the plan & pay $6k for you & DD2 in L&D then later in the year your DH needs a $$ surgery it will be covered 100% because you've already reached your family OOP max.

.

So in your example lets assume it was a single surgery that cost $10k. You would pay the first 1500 then the listed co-insurance up to the OOP max. So of your co-insurance was 20% It would be calculated on the remaining 8500. That amount is 1700 but you would max out at $3k. (1500 deductible & 1500 co-insurance)

Does that make sense?

[Ashley&Scott]

Jul 2, 2015 17:04:01 GMT -5 @starry said:

Jul 2, 2015 17:01:05 GMT -5 jewel said:

It's not the answer you're hoping for, LOL.

I had never had a HDHP before our current plan, and I was under the impression that $1500/$3000 meant that any one person would cap at $1500, with the family total max at $3000.

Wrong. The way it's worded in the benefits paperwork is deceiving

Yeah I figured as much because I knew I paid the family OOP max when I had DD1 but I figured that was due to us being in the hospital forever (four nights while I was recovering, they charged at least $5k to her for that even though she had no medical problems).

Mainly I want to know how much DD2's expenses are going to be because if they are high I want her on my plan, and if they are low I want her on my husband's plan. Blah. 

Call your hospital & ask how they bill for newborns, they should be able to give you estimates for average newborn care. You can also call your insurance, they can help you estimate the costs related to delivery & newborn care. Sometimes copays & co-insurance are waived for newborns.

With the numbers you gave you're guaranteed not to pay more than $6k total for both of you if she's on your plan. What are the specifics of your DH's plan?

[whitemerlot]

Jul 2, 2015 16:47:48 GMT -5 ebeth said:

Yes. Individual deductibles/OOP max only apply to individual plans.

I didn't realize this. Yikes!

I need to call. My plan says
Out of pocket max:
$3,000/person
$6,000/family

[jewel]

Jul 2, 2015 17:04:01 GMT -5 @starry said:

Jul 2, 2015 17:01:05 GMT -5 jewel said:

It's not the answer you're hoping for, LOL.

I had never had a HDHP before our current plan, and I was under the impression that $1500/$3000 meant that any one person would cap at $1500, with the family total max at $3000.

Wrong. The way it's worded in the benefits paperwork is deceiving

Yeah I figured as much because I knew I paid the family OOP max when I had DD1 but I figured that was due to us being in the hospital forever (four nights while I was recovering, they charged at least $5k to her for that even though she had no medical problems).

Mainly I want to know how much DD2's expenses are going to be because if they are high I want her on my plan, and if they are low I want her on my husband's plan. Blah. 

Expenses, as in, the birth? If so, you could probably do both.

When DS was born, his expenses were covered under my policy for the first month (not as an additional member, just my individual policy through my employer). We had 30 days to add him to either of our policies, and added him to my husband's (the HDHP) once he was a couple of weeks old. So, the birth was all billed to my HMO plan (100% covered), and his ongoing healthcare was covered by the HDHP.

[Cicero]

Our OOP Max is for the family.

[arch01]

Jul 2, 2015 17:04:01 GMT -5 @starry said:

Jul 2, 2015 17:01:05 GMT -5 jewel said:

It's not the answer you're hoping for, LOL.

I had never had a HDHP before our current plan, and I was under the impression that $1500/$3000 meant that any one person would cap at $1500, with the family total max at $3000.

Wrong. The way it's worded in the benefits paperwork is deceiving

Yeah I figured as much because I knew I paid the family OOP max when I had DD1 but I figured that was due to us being in the hospital forever (four nights while I was recovering, they charged at least $5k to her for that even though she had no medical problems).

Mainly I want to know how much DD2's expenses are going to be because if they are high I want her on my plan, and if they are low I want her on my husband's plan. Blah. 

you should have 30 days post-birth to add her to either plan.  this shouldn't be something you have to decide right this second. but i agree w/ PP-talk to the hospital. 

we were in a similar position-$$$$ expenses for DS=my plan. $ expenses=private plan. my plan covered "reasonable" expenses for DS under my childbirth coverage. 

[whitemerlot]

I just double checked and ours is a max of $3000 for one person or $6000 for the family.

[bunch]

Jul 2, 2015 17:25:42 GMT -5 @starry said:

Jul 2, 2015 17:20:10 GMT -5 Ashley&Scott said:

Call your hospital & ask how they bill for newborns, they should be able to give you estimates for average newborn care. You can also call your insurance, they can help you estimate the costs related to delivery & newborn care. Sometimes copays & co-insurance are waived for newborns.

With the numbers you gave you're guaranteed not to pay more than $6k total for both of you if she's on your plan. What are the specifics of your DH's plan?

I think the OOP max is like $8k for the family / $4k deductible (bunch?)

DH and DD1 have maybe had $300 applied against it this year.

Close, the oop is based on salary, so we're at 11,000.