You're probably getting close to picking a health insurance plan, but you just want to make sure you know everything you can about it first.
That's smart.
Being an independent insurance agent, clients ask me all the time to tell them what plan is the best for them.
Unless you know all the details, it's hard to get a good answer. Lucky for you we're going to go over all those details right now.
Click below to view the summary of benefits and follow along.
MedMutual Market 1750 (Silver)
NOTE: The only difference is that if you buy this plan with a tax credit through Ohio's health insurance marketplace (or exchange) the word "Market" is used by Medical Mutual to tell the difference.
In-Network vs. Non-Network
The first thing you will notice is that there are two columns, one for in-network services and another for non-network.
You are ALWAYS going to want to do everything you can to “stay in-network.” If you don't, you're setting yourself up for a much more expensive and unpleasant adventure.
Here you can see non-network limits are A LOT higher than in-network.
Deductible
The 1750 plan has a, $1,750 single and $3,500 family deductible. I wonder where they get the names for these plans…?
Watch the video below for more detailed explanation on embedded vs. aggregate deductibles.
That is the amount of money you will have to pay, upfront essentially, before your plan kicks into the co-insurance.
Maximum Out-of-Pocket (MOOP)
Since the 1750 plan has 25 percent coinsurance your maximum out-of-pocket is going be $6,850 for a single and $13,700 for a family. Once you hit those limits Medical Mutual will pay 100 percent for any covered medical services for the rest of the year.
Or, to put it another way the MOOP is the bottom line number you need to be concerned with the most.
It's important to notice that your Non-Network MOOP is REALLY high like $100,000 and $200,000 high. That means the bills will keep coming until you reach $100,000 for a single person or $200,000 for a family.
Don't get too caught up with it too much though because there are only a handful of situations you could find yourself where that would be a problem.
Co-Insurance
This silver plan has 75/25 coinsurance split, which means after you pay the deductible Medical Mutual will pay for 75 percent of your remaining bills until you hit your MOOP.
Except for non-network treatment which will have 50 percent coinsurance.
Accumulation Method
Medical Mutual has changed all of their deductibles to be embedded. In less fancy insurance terms that means split. Instead of your entire family working towards the $3,500 deductible, you'll now have two $1,750 deductibles shared by any combination of family members.
Overall Benefit Period Max
Like what data from all internet service provider should be, it's unlimited, or in other words your health insurance never runs out.
Medical Mutual will keep paying for as much covered medical treatment that you need for the year and lifetime of the policy.
Dependant Age Limit
After an Ohio law change this year, now some insurance companies have rolled back the age limit to match the federal limit, which is 26 years old.
That means you can keep your children on your health insurance until the end of the month they turn 26. Of course you are welcome to kick them off well before that, but that's entirely up to you.
Benefit Period
January 1st, through December 31st.
It doesn't matter when your policy starts, your deductible and MOOP will always reset at the end of the year.
Physician's/Office Services
Here's where things get a little tricky.
This plan technically has a $30 copay for your primary doctor and a $60 copay for any specialist or urgent care visit.
However, for Medical Mutual to be able to keep this plan a silver plan they had to work the numbers here a little harder.
The copay dollar amounts mentioned above are for an unlimited number of visits during the year, but they subtracted from the total negotiated rate instead of being a flat fee.
Let me explain a little more.
As an example, if you were to go see a primary doctor for a sinus infection, that doctor might try and bill you $100. If they're an in-network provider, Medical Mutual will have already negotiated that rate down somewhere in the $50-$60 range.
That's the number you would subtract $30 from. If the visit was $50 than you would have $20 left to pay for, which would be paid through your coinsurance on the plan.
Which would mean 25 percent of $20 is $5, so your total cost for the visit would be $35. Which isn't bad, it just takes a lot more work to figure it out.
While it's not a perfect solution and more annoying than anything, it's still going to be one of your best options for a copay in 2016.
From this point on you will notice that everything is pretty much split 50/50 between you and Medical Mutual for non-network treatment. With the exception of prescription medication and emergency room visits.
Preventative Services
There are a host of preventative services outlined by the Affordable Care Act that have to be covered at 100 percent, before the deductible. In other words, free.
The preventive services that didn't make the ACA list will go towards your deductible and then into co-insurance.
However, if you go out-of-network for those free preventive benefits, they won't be free anymore and will be subject to your out-of-network deductible and coinsurance. But that's not something you're ever going to do, right?
Outpatient Services
Everything except non emergency use of the emergency room will apply to your deductible and coinsurance.
You'll also have a copay of $300 for the emergency room that will work just like the ones we talked about earlier.
Non-emergency use of the emergency room is NOT covered. So, think twice before you run to the emergency room after your doctor's office closes for a sinus infection.
You should also notice that for mental health and substance abuse office visits also have a $30 copay.
Inpatient Services
This covers stuff like hospital stays, maternity care and surgery. Everything under this category is going to be subject to your deductible and coinsurance then covered in full after.
Additional Services
This is where things like your ambulance ride, hospice care and organ transplants are covered. Again, all of these services will go towards the deductible and then into co-insurance, which is 25 percent.
Prescription Drugs
You're going to have a standard copay for your prescription medication with the 1750 plan.
You'll have two different copay's depending on how you get the prescription filled, either over the counter or through mail order.
Here's how those copays breakdown.
Generic
In-Network Retail: $30 Copay (30-day Supply)
In-Network Mail Order: $90 copay (90-day Supply)
Preferred Brand
In-Network Retail: $60 copay (30-day Supply)
In-Network Mail Order: $180 copay (90-day Supply)
Non- Preferred Brand
In-Network Rtail: 50% up to $350 max per medication (30-day Supply)
In-Network Mail Order: 50% up to $1,050 max per medication (90-day Supply)
Specialty High-Cost
In-Network Retail & Mail Order: 50% up to $350 max per medication (30-day Supply)
The Bottom Line
Health savings accounts really cut to the chase and simplify most of the process. Hopefully this breakdown gives you a decent understanding of what's covered and how the plan works.
If you want to know more about the actual bank account portion of HSA's you can read about that here.
Next Step
Let's find out if this type of plan actually makes sense for you by taking a look at how you would need to use it.
