Stupid Health Insurance Deductible Question

[motzie]

That sounds right to me.

Do you have a family out of pocket max?

[linz]

That's just your deductible, not cap. So you pay $500 and then insurance kicks in - I guess depending on plan. A lot of plans have a deductible then coinsurance, say 80/20. So after deductible was met you would pay 20%. There is usually a max out of pocket for the year. If it is $5,000 that is the max you would pay for yourself in the calendar year. 

[Deleted]

I don't think so, if it's a family deductible with no per-person max, all of you would contribute to the 1k limit until it's met. I could look at my healthcare stuff last year, since I hit the deductible in a few week (c=section lol).

[megkat]

Depends on your plan. I had one in the past where DH and I each had to meet our individual deductible. Our current plan, it's an aggregate deductible- so it's 2600 for the two of us, doesn't matter how it gets hit. We're at about 68% of it so far, the breakdown of which is 54% from me (thanks IF treatments!), and 14% DH. So even though I'm over the 1300 dollars that would be my "half", I still have to keep paying until the two of us together meet our full deductible.

[dottyblue]

Given how much insurance sucks, I would assume that it's $1k out of pocket regardless of who is filing the claims. Your benefits administrator should be able to confirm though.

[zarapipe]

Totally depends. I think the deductable would be 500 but is there coinsurance, most plans have 10, 20 or 30% coinsurance after your deductable has been met.

[djc315]

I think it will end up being plan dependent. I called and asked, twice, and ours is by person.

[zarapipe]

Also keep in mind that if this is through work you probably are paying this with pre tax dollars so it's not 200 more, but 200 pre tax, which depending on your bracket will be less than 200 out of pocket more if you go with the higher plan

[Ashley&Scott]

Each person should have a deductible & annual out of pocket max. The plan will also have a family deductible & OOP max, but that's usually only to your advantage if you have more than 2 people on the plan.

For example, my plan is:
Deductible: $1,000 individual / $2,000 family
Out of pocket max: $3,000 individual / $6,000 family

So on my plan I would have to meet the $1,000 deductible then pay my co-insurance (20%) until I reached $3,000. Co-insurance is waived for some services. (for example doctor appt are just $20 copay, but co-insurance would apply for any surgery.)

[Ashley&Scott]

swizz - how many specialists do you see? Are your regular doctors considered in network for plan 1?

[AmyRI]

I think you're correct. If it was $1000 no matter what, why would they bother with a per person number?

I would go with plan 1. Yes the premiums are higher but copays are lower and no coinsurance for major events is a big plus to me. That's how you rack up big bills and hit the OOP max, which I would really avoid. Plus you're pretty much guaranteed to hit the deductible, which means plan 2 really costs premiums +85/mo for that.

Will you be paying specialist copays for C's ASD treatments? Because that difference adds up fast as well if she's got multiple appts a month.

[Ashley&Scott]

swizz are you anticipating tubes? (ETA: I just looked it up, we spent $1,900 on his tube surgery, deductible + 20% coinsurance)

I would try to estimate how many PCP & specialist visits you'll have. Guess any surgeries then do the math.

Personally I would lean towards the plan with more coverage.

And I would assume the family OPM is $8k.

[steamboat185]

It depends on how the employer sets up the plan it can be administered either way.

[broadsheet]

Would you have to pay the deductible first before copays kick in for ABA or any other kind of therapy?

I personally would do plan 1 because of the ASD diagnosis. (Grain of salt disclaimer: I preemptively switched my girls to H's insurance during open enrollment because his covers autism therapies and mine doesn't, even though we are still in the middle of the eval process and don't know if she has ASD.)

[Deleted]

Our plan is per person. So for that plan 2 say my DS is always sick he would go up to $500 and then more stuff would be covered up until a max of $4000 per year for him.

[cjeanette]

The way I have understood it is that if one person reaches $500 on their own they have met their deductible for the year.

As a family once you meet 1k in expenses the whole family has met the deductible.

[christy082]

It definitely depends on the plan

[jewel]

It really depends on how your plan is set up. Ours is individual/family, so in your example, we would always have to pay the higher amount because we have a family plan. I had assumed (wrongly) for quite some time, that when it said individual/family deductible of $1500/$3000 it was $1500 for any one person and $3000 total for everyone, but it really meant $1500 for an individual PLAN or $3000 for a family plan.

[megkat]

Apr 15, 2016 10:16:53 GMT -5 swizz said:

Apr 15, 2016 9:58:32 GMT -5 jewel said:

It really depends on how your plan is set up. Ours is individual/family, so in your example, we would always have to pay the higher amount because we have a family plan. I had assumed (wrongly) for quite some time, that when it said individual/family deductible of $1500/$3000 it was $1500 for any one person and $3000 total for everyone, but it really meant $1500 for an individual PLAN or $3000 for a family plan.

Yeah, see I don't think it's a family plan. That's an option, but this is Employee + Child, as opposed to Employee + Family. 

I'd still definitely check with whoever the benefits coordinator is. My plan is an employee +1 plan (you can choose to have either your spouse or a child on it), not a family plan, and it's still an aggregate deductible.

[coribelle26]

It may depend on the plan but when we had a high deductible plan, the higher of the two applied even if only one person had any expenses. Ours was like $2500 for an individual, $5000 for the family - it was just H and I on the plan and the year I had a miscarriage we paid everything OOP up to $5000. He had little to no personal medical expenses that year.

[ijack]

Apr 15, 2016 8:23:38 GMT -5 swizz said:

Apr 15, 2016 8:04:37 GMT -5 motzie said:

That sounds right to me.

Do you have a family out of pocket max?

It doesn't say anything about a Family out of pocket max. Just the Annual Out of Pocket Max is $4000/$8000. 

I'm debating between two plans. This is for employee and child.  

Plan 1: $621/mo
No Deductible
$15 copay for PCP, $35 for specialist
OOP Max - $3500/$7000
ER - $200 copay
Inpatient - $200/day, $1000 max
Outpatient - $150 copay

Plan 2: $420/mo
$500/$1000 deductible
$25 copay for PCP, $50 for specialist
OOP Max - $4000/$8000
ER - 20% after deductible
Inpatient - 20% after deductible
Outpatient - 20% after deductible

The ASD coverage seems to be the same between the two regarding what they cover and what they don't. 

Money is also a really big issue -- the $200/mo difference feels huge, but writing it out maybe it isn't?

so the 2nd number is the family deductible. In your case it's the same as double the individual, if you had more people it would still be the same family deductible.
Plan 2 will save you $2400 year in premiums, but then $500 of that will be eaten up for your deductible, so $1500 savings. OOP max difference is $500 for one person, so you'd still come out ahead with #2.