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Question for Health Insurance Experts

Old 10-17-2016, 12:51 PM
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I just can't wrap my mind around this...

I'm looking at 2 health insurance plans, and I'll use sample numbers to keep it simple:

Plan 1 has $3,000 max out of pocket, 10% co-insurance and $1,000 deductible

Plan 2 has $3,000 max out of pocket, 0% co-insurance and $0 deductible

Plan 2 is $1,500 more per year than Plan 1. What I can't seem to grasp is that with the maximum out of pocket the same on both plans, what is the benefit of 0% co-insurance and $0 deductible with a higher premium? Somehow, you'll be out-of-pocket the same amount for both plans, correct? It's just a matter of what gets applied to the max out of pocket I would imagine.

With the lower priced plan, the deductible applies towards the maximum out of pocket, so with a $0 deductible and 0% co-insurance plan, how is money applied to the max out of pocket?

I already spoke to a benefits counselor and they were stumped themselves for the most part, and couldn't tell me why someone would opt for the higher priced plan.

Any help would be appreciated!
Old 10-17-2016, 12:54 PM
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How much health care have you needed in the last 5-10 years?
Old 10-17-2016, 12:55 PM
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I opted for the best plan I could get through my employer. It is a difference of 1500 a year between the cheaper plan. Im not an expert but my decision came down to ppo vs hmo. I wanted to choose my own doctor so I went with the PPO.
Old 10-17-2016, 01:35 PM
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Originally Posted by David B. View Post
How much health care have you needed in the last 5-10 years?
Probably an average amount, with an unexpected surgery this year.
Old 10-17-2016, 01:36 PM
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Originally Posted by fjmaverick View Post
I wanted to choose my own doctor so I went with the PPO.
Both plans are PPO's...I just don't get the correlation between having no co-insurance and no deductible plus a higher premium, with the same max out of pocket as the cheaper plan.
Old 10-17-2016, 01:41 PM
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Read the small print. Some deductibles are per event, not per year. Maybe that could be one difference?
Old 10-17-2016, 02:49 PM
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The $3000 OOP would be for out of network if you have $0 deductible and 0% coins that's all it could be.
Old 10-17-2016, 02:53 PM
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Originally Posted by T Hard11 View Post
The $3000 OOP would be for out of network if you have $0 deductible and 0% coins that's all it could be.
I thought the same thing but in the new world of Health Insurance I would want that confirmed. If your health take the cheaper plan. Even if something happens you still only have a $1,000 ded v/s paying $1,500 more per year.
Old 10-17-2016, 02:57 PM
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Are you sure the deductible is included in the max oop?
Old 10-17-2016, 03:18 PM
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Originally Posted by johnb48 View Post
Are you sure the deductible is included in the max oop?
Yes, that's why I'm confused, and both examples are for "in network" services, but the "out of network" expenses are the same for both plans.
Old 10-17-2016, 03:20 PM
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Originally Posted by Commocean View Post
what is the benefit of 0% co-insurance and $0 deductible with a higher premium?
You get "first dollar" benefits with this plan meaning benefits are paid without having to satisfy any cost-sharing (i.e. coinsurance, deductible) requirements first.

First dollar benefit plans are always going to be more expensive than "less rich" plans.

Are you sure it is 0% coinsurance and not copay???

Originally Posted by Commocean View Post
Somehow, you'll be out-of-pocket the same amount for both plans, correct? It's just a matter of what gets applied to the max out of pocket I would imagine.
Yes but with the "less rich" plan, you have to meet your deductible first before any benefits are paid, and according to your posts, these dollars will apply toward the OOP. With the "richer" plan, you may never have to pay any out-of-pocket and never have to worry about hitting the max since benefits will start to pay from "first dollar".

Originally Posted by Commocean View Post

With the lower priced plan, the deductible applies towards the maximum out of pocket, so with a $0 deductible and 0% co-insurance plan, how is money applied to the max out of pocket?
it won't if you stay in-network.

Also, check to make sure there are not two sets of deductibles, coinsurance, out of pocket maxes, etc....one for in-network and another for out.
Old 10-17-2016, 03:24 PM
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They should give everyone a FREE Colonoscopy when You HAVE to sign up for Health Insurance !! OH,That's right they do....Can You say Bend Over!
Old 10-17-2016, 03:31 PM
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How would you even be able to get to the $3K out of pocket if you 0 deductible and 0% co-insurance?

Are you sure plan #2 isn't a $3K deductible and then no co-insurance?
Old 10-17-2016, 04:06 PM
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Originally Posted by richeerich View Post
Are you sure it is 0% coinsurance and not copay???
Positive...On both plans, there's a 30% co-insurance for "out-of-network" services, but the basic plan has a deductible, and the premium plan does not...The premium plan has $0 deductible and 0% co-insurance for "in-network" services...There are additional benefits on the co-pay as well...For example, the co-pay for the basic plan is $30, and $25 on the premium plan...There is also a fixed co-pay for emergency room visits and inpatient care, whereas with the basic plan, you have a deductible or co-pay + 10% co-insurance..

Originally Posted by richeerich View Post
Yes but with the "less rich" plan, you have to meet your deductible first before any benefits are paid, and according to your posts, these dollars will apply toward the OOP. With the "richer" plan, you may never have to pay any out-of-pocket and never have to worry about hitting the max since benefits will start to pay from "first dollar".
Well, I'd still have co-pays for doctor visits, pharmaceuticals, etc..I thought with the premium plan you might be hedging for a major medical event, but what still has me perplexed is that with the maximum out-of-pocket the same on both plans, a major event is capped by the max out-of-pocket...
Old 10-17-2016, 04:08 PM
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Originally Posted by Shag View Post
How would you even be able to get to the $3K out of pocket if you 0 deductible and 0% co-insurance?
Via co-pays for emergency room visits, inpatient care, etc...But, with the same max out of pocket on both plans, it limits your maximum exposure by the same dollar amount, which is what has me baffled...

I'd say the premium plan might be for folks that can't afford the deductible, but you still have the max out-of-pocket, so it's just a matter of when that is met..
Old 10-17-2016, 04:18 PM
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Originally Posted by Commocean View Post
Via co-pays for emergency room visits, inpatient care, etc...But, with the same max out of pocket on both plans, it limits your maximum exposure by the same dollar amount, which is what has me baffled...

I'd say the premium plan might be for folks that can't afford the deductible, but you still have the max out-of-pocket, so it's just a matter of when that is met..
Check and see if those co-pays go towards the maximum out of pocket. A lot don't. That might be the difference.
Old 10-17-2016, 04:30 PM
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Originally Posted by Shag View Post
Check and see if those co-pays go towards the maximum out of pocket. A lot don't. That might be the difference.
They do...They don't go towards the deductible, but they do apply towards max OOP...
Old 10-17-2016, 04:41 PM
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First thing I'd do on any PPO is to look and see if my favorite physicians and specialists are included on their approved list of doctors.

My wife is a medical professonal, and she's really, really good at working the system. She finally came to the conclusion that our old HMO's were fine for those just having the sniffles. But if you have something really wrong with you, HMO's are going to be slow getting you to the really best surgeons, specialists, etc.not working full time for them.

My wife suffered greatly with a chronic OB problem--for years. When we went on a PPO, her problem was diagnosed in one visit and laproscopic surgery took care of her. Kaiser Permanente (Atlanta) jerked her around for years.

No thank you to HMO's if there are other alternatives.
Old 10-17-2016, 05:23 PM
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Originally Posted by Commocean View Post
Probably an average amount, with an unexpected surgery this year.
Not sure what you consider average but I would figure out the total out of pocket cost of the plans and compare them to your expected health care costs as well as how much cash you usually have available. If you use it a lot then a lower out of pocket makes sense. If you are younger and generally healthy then higher deductibles shouldn't be a show stopper.

Also look at your doctors, hospital, pharmacy, etc to make sure they are in network. These days I would not be as worried about getting referrals since many have automated the process compared to having to go in to see the doctor.
Old 10-17-2016, 05:36 PM
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I'm not an expert but I used to bill insurance a lot, but basically from what I recall with plan 1, you have a 3k OOP and 1500$ deductible. With this plan it should be when you hit your 1500 deduct you will be paying X amount until you hit your OOP then you'll have to pay 10% of the bill thereafter even after meeting your OOP/deductible.

With plan 2, when you reach your OOP the entire bill would be covered by insurance 100% and you will NOT owe 10% of the bill, hence why bill 1 would be cheaper.

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