You're knee deep in this health insurance stuff and you're getting close to narrowing down what plan might be right for you and your family.
You want to know more about this gold plan from Aetna and this $5 copay thing sounds interesting.
Chances are you've probably heard of Aetna before not only are they the third largest health insurance company in the world, they're also one of the biggest companies in the world period.
Let's go in depth and break this plan down line-by-line and help you know exactly what you can expect from it.
Click here to view the summary of benefits for Aetna's $5 Copay plan and follow along.
What's a POS Plan?
You might notice three letters that are a little different next to this plan name and they are POS or Point of Service.
Other letters that a more common in this spot are PPO (preferred provider organization) and to a lesser extent HMO (health maintenance organization).
A POS plan was initially designed to be a mix of the two, however this plan from Aetna actually works identically like a PPO plan.
That means you don't need to a primary care doctor to direct all of you treatment and deal with referrals to specialists.
The only reason Aetna is using the POS name is probably due to some complicated legal filing issues.
In-Network / Out-of-Network
This is the absolute first line you see on the summary of benefits and this is to help you distinguish between how the plan works when you are getting treatment from a preferred doctor
Deductible
If your staying in the network, you would have a single deductible of $1,400 or $2,800 for a family.
Co-insurance
This plan features the most common coinsurance split with an 80/20 share of the network bills. You will start paying 20 percent of all you covered medical bills after you pay your deductible.
For example, if you have a $3,000 MRI you will pay the first $1,400 (single person in-network) which takes care of your deductible and then you will split the remaining $1,600 with Aetna at 80/20. In this case you would pay $320 and Aetna would pay $1,280. Not a bad deal.
Out-of-Pocket Maximum
This is your big picture, bottom line number that should be one of the most important to be aware of when buying health insurance.
For this plan you could pay up to $5,000 by yourself or $10,000 for your family.
You'll want to take a second and glance over at the Out-of-Network column and see that it says “Unlimited.” That means you will never stop paying for services that are performed out-of-network.
Primary Care Visit Copay
This is probably the one benefit that will get your attention the most and stand out from the other plans you are considering.
You will only pay $5 every time you have to go see your primary doctor. Most other copays will be in the $20-$30 range.
Specialist Visit Copay
If you primary care doctor can't handle something and you are required to see a specialist, then you will have to $40 every time you make one of these appointments.
This copay is a little more in line with the average specialist copay as they can range from $40-$50 for each visit.
Hospital Stay
For any service that doesn't have a specific copay you will have to meet your deductible then split the remaining bills through your co-insurance.
Chances are if you find yourself in the hospital even for one day you will meet your deductible and get into your co-insurance.
Outpatient Surgery
Just like your hospital stay, any quick surgery where you aren't kept over night will go to your deductible then into you co-insurance.
Emergency Room Visit
Now we are back to the copay's for a second. If you find yourself in ER you will have to pay a $250 copay after your deductible for that trip. If your condition was serious enough that you had to be admitted to the hospital, than your copay would be waived.
Have a copay on top of a deductible is a little stiff in my opinion, but it could end up being better than what you would have to pay through your co-insurance.
Urgent Care Visit
If one of your little ones develops a slightly strange and possibly alarming rash after normal doctors office hours and you don't want to find out what it will look like in the morning untreated than you will be paying a $75 copay (without meeting your deductible) for the visit.
This is a fairly average copay for this type of service, although I have seen them as low as $50 on some plans.
Preventive Care
First it's important to note that age and frequency limits apply here. However, if you're getting a preventative service that is outlined by the Affordable Care Act it would be covered in full before the deductible.
Or said more simply, free.
Diagnostic Lab Testing
Now we're back to the deductible co-insurance routine with you lab work like blood test and such.
After your deductible is taken care of you will pay 20 percent of the remaining bill.
It's also important to note here that even if you don't have a copay for a specific service, Aetna or any health insurance company will have a negotiated or discounted rate that is much less than if you were have the test done without insurance.
While that discounted rate will vary from service to service, you will see some of the biggest discounts on your lab testing.
Diagnostic X-Ray
You can just read the last section again. Deductible and co-insurance is how you will pay for x-rays.
Imaging (CT/PETscans, MRI)
At the risk of sounding like a broken record, these types of test will first fall under the deductible and then into your co-insurance.
It's pretty rare to find a copy for these types of test, however there are health insurance companies in Ohio who do.
Pediatric Vision
Your kids are going to get one visit a year that is like preventative benefits, covered in full or essentially free.
Pediatric Dental
You can take your kids twice a year for free to in-network dentists for their check-up's and routine preventive care. If they need any basic dental care like a filling, you will have to pay 30 percent of your the bill after your deductible.
Prescription Medication
This might be a little confusing, but you are going to have a separate pharmacy deductible of $250 before you get into the different copays. Which means, just like your primary deductible, you will have to pay the first $250 of medication costs before the copay kick in.
Here's how those copay's breakdown:
- Preferred Generic - T1A - $3 / T1 - $10
- Preferred Brand - $35
- Nonpreferred Brand - $70
- Specialty Drugs - Preferred 30 percent (after your deductible) / Nonpreferred 50 percent after the deductible.
So that looks a little more confusing that it probably needs to be, but let's break this down a little more.
Starting at the top, your generic medications could fall under one of two options for a copay. The T1A is what Aetna considers value drugs and T1 as preferred generic drugs.
In all honesty, most generic medications are so affordable now copays are rarely necessary.
The second option Preferred Brand is a little more straight forward. If a brand name prescription is on Aetna's good list you will only pay $35.
If a brand name medication isn't on their good list it jumps to $70, which is a little higher than most plans with copays for medication.
Finishing things out, we're back into confusing territory with specialty medication (which are pretty rare) that has a two tier structure for preferred and nonpreferred.
Again just think of this as a good list and bad list. The good list will cost your 30 percent and the bad 50 percent.
The Bottom Line
The $5 office copay and $3 generic drug copay are probably the two benefits that make this plan stand out from the rest.
Are they enough to justify serious consideration on your part?
It's possible, but I doubt it.
Next Steps
If this plan doesn't make sense, let's take a look at a few the might and how they stack up against each other.
