I thought I would try something different for a couple weeks and go in-depth on a series of new health insurance plans offered inside and out of Ohio's Health Insurance Marketplace, or through Obamacare.
We are going to kick things off this week with Medical Mutual's Market Classic 1000 Gold plan, the “top-of-the-line” traditional plan offered in the Marketplace.
Click here to view the summary of benefits and follow along.
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.
Deductible
The Market Classic 1000 Gold has a, you guessed it, $1,000 single deductible and $2,000 family deductible. Watch the video above for a 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.
Non-network it's $3,000 single and $6,000 for a family.
Maximum Out-of-Pocket (MOOP)
This plan will feature a $5,000 single or $10,000 family MOOP, which means you will never pay more than $5,000 for yourself or $10,000 for your family in covered medical services for the year.
To put this another way, that's your worse case scenario number.
It's important to notice that your Non-Network MOOP is unlimited. That means the bills will just keep coming and there's no cap on what you could potentially spend. Now you believe me when I say stay in-network.
Co-Insurance
The Classic Gold has 20 percent co-insurance, or 80/20 coinsurance, which means you will split the remaining medical bills with Medical Mutual based on that percentage.
For example, if you have a $3,000 MRI you will pay the first $1,000 which takes care of your deductible and then you will split the remaining $2,000 with Medical Mutual at 80/20. In this case you would pay $400 and Medical Mutual would pay $1,600. Not a bad deal.
Accumulation Method
Watch the video breakdown for a more detailed explanation on embedded vs. aggregate deductibles.
Overall Benefit Period Max
Like what data used to be like on your cell phone plan, it's unlimited, or in other words your health insurance never runs out.
Medical Mutual will pay for as much, covered, medical treatment that you need for the year and lifetime of the policy.
Dependent Age Limit
You can keep you children on your health insurance in Ohio until they are 28 years old. Of course you are welcome to kick them off well before that, but they CAN be there until the end of the month in which they turn 28.
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.
Physicians/Office Services
The Classic 1000 Gold is the only plan in Ohio's Marketplace that has “unlimited” doctors office and prescription copays from Medical Mutual.
In this case you will pay $25 for every visit to your primary doctor and $50 for every specialist and urgent care visit.
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.
Outpatient Services
Everything except emergency room visits and non emergency use of the emergency room will apply to your deductible and coinsurance.
You will have a $250 copay for the ER.
Non-emergency use of the emergency room is NOT covered. So, think twice before you run to the emergency room after your doctors office closes for a sinus infection.
Inpatient Services
This is going to include things like hospital stays, maternity care and surgery. Everything under this category is going to be subject to your deductible and then split with you through co-insurance.
Additional Services
Here you will find coverage for ambulance rides, hospice and organ transplants. Again, all of these services will go towards the deductible and then into co-insurance.
Prescription Drugs
You will have copay for all your medications that will be either for a 30-day retail supply or a 90-day mail order.
Here's how the copay breakdown based on purchase method and medication type.
Generic
In-Network Retail: $15 copay for up to a 30-day supply
In-Network Mail Order: $45 copay for up to a 90-day supply
Preferred
In-Network Retail: $30 copay for up to a 30-day supply
In-Network Mail Order: $90 copay for up to a 90-day supply
Non-Preferred
In-Network Retail: $50 copay for up to a 30-day supply
In-Network Mail Order: $150 copay for up to a 90-day supply
Specialty High-Cost Drugs
In-Network Retail: 20% up to a $150 maximum per script
In-Network Mail Order: 20% up to a $450 maximum per script
We all know what a generic drug is, but a preferred brand name is a name brand drug that Medical Mutual likes, a non-preferred drug is one they don't get along with so well.
The Bottom Line
There's obviously a lot of moving parts in a health insurance policy, but hopefully this breakdown gives a decent understanding of what's covered and how things are paid for.
Even more obvious, this gets a heck of lot easier when you work with someone who knows what their doing and can simplify the process for you.
You Tell Me
I've got two questions for you.
One, what questions do you have left about Med Mutual's Market Classic 1000 Gold plan?
Two, what other health insurance plans would you like to see a detailed breakdown of?
