Whether it’s a workplace health insurance plan or a state Healthcare Marketplace, you have to choose the one that suits you best from multiple plans. How do you weigh them? When I read the know-how article, there are explanations such as “First check if your doctor is in the network”. There are many things, but what about? Then, I feel that it is difficult to make a clear statement. Also, there may be a cost comparison table or a calculator that allows you to check the annual cost, but how do you read it? A lot of information is presented, but do you ever wonder what to compare and how?
For example, if you had a choice of such a plan, what should you compare and how? No one knows what kind of illness, what kind of treatment is needed, and how long it will last, so it is almost impossible to calculate properly and choose the best one. This time, I would like to think about something like a point when I get lost like that.
See Deductible
First, let’s see if there is a Deductible. Those without a Deductible setting, that is, those with a Deductible of zero, will be covered by insurance from the first service even if they receive medical services soon after the beginning of the year. On the other hand, if you have a Deductible setting, insurance coverage will start only when you pay the amount from your pocket.
Since the Zero Deductible plan is often an HMO (Health Maintenance Organization), it may be necessary to stay in the network, or if you want to be a specialist, you may need a referral from the PCP, but compensation In terms of it, it’s a low-risk, conservative plan. Even if the monthly insurance premium is a little high, it is a reassuring choice for those who do not want to go to the hospital while worrying about the price.
The good thing about the Zero Deductible plan is that if you think something is wrong, you can feel free to ask a doctor. For example, if you think that it costs $ 150 or $ 200 for a small visit, you might think a little. If you think that it costs more money if it is CT or MRI, it means that you can not easily take the test if it is “a little strange”. With the Zero Deductible plan, you can rest assured that all the rest will be covered if you pay for Co-pay, and you may be more active in maintaining your health.
If you have a plan with Deductible, you should be prepared to pay for it and prepare for it. Instead of “don’t spend medical expenses as much as possible” and “don’t go to the hospital as much as possible”, I’m going to get rid of my stomach up to Deductible in advance. If you don’t need it, I think it’s better to be lucky. Especially if you have small children or are older than the age at which you start to have health problems, you should avoid hesitating to go to the doctor.
A and B are zero deductible plans. Office Visit (outpatient) will be covered by insurance if you pay $ 20 for Co-pay, and Impatient (inpatient) will be covered by insurance if you pay $ 250. Surgeon is not self-paying and is covered by insurance. The Out-of-pocket Maximum is quite different between A and B, but both are very generous in terms of coverage, so you may be hospitalized many times or many times. It is expected that there will be no difference unless you go to the hospital (the probability that the out-of-pocket maximum will be higher than A’s Out-of-pocket Maximum). It is expected that A and B will probably have different network scopes and affiliated hospital groups. If you have a doctor or hospital affiliate that you like, it’s a good idea to look at the contents.
Unfortunately, employer benefits have often not offered a zero Deductible plan these days. Also, I think that the number of zero deductible plans has decreased in the marketplaces of states.
See Out-of-pocket Maximum
Let’s compare the Out-of-pocket Maximum for plans other than A and B. First, make sure that this is the maximum amount you will have to pay in a year in the worst case. It may be unlikely that you will be spending so much, but it cannot be said that you should be prepared to pay this amount immediately. In the first place, insurance is risk management to deal with damages that make it impossible for households to survive due to unexpected events, so you should not be able to stand even if you have insurance. .. Make sure the Out-of-pocket Maximum is within expectations.
Think in Family. The Out-of-pocket Maximum with the highest C is set at $ 14,200. This plan has a low deductible, so it is easy to start insurance coverage if you pay a little, but the co-insurance after that is as high as 30%, and if it is a little hospitalization or surgery, it will be expensive, Out-of- It can be said that it is a plan that tends to bear the cost up to the pocket maximum. Insurance premiums may be cheap, but the risk is high. If you are healthy, you may be able to reduce costs, but once you need medical services, the cost will increase.
D and E have out-of-pocket maximums of $ 6,400 and $ 9,000, so even in the worst case, it’s easier to bear than C. D has a lower Out-of-pocket Maximum and a lower Deductible, so insurance coverage will begin sooner. But D’s Co-insurance is 20%, twice that of E. Since the deductible is low, insurance coverage will start early, but since the Co-insurance is 20%, the out-of-pocket cost will be twice as much as E. However, if the medical expenses are getting higher and higher, the Out-of-pocket Maximum will be reached sooner, so it is a plan that does not cost more than $ 6,400. Since it is a High Deductible Plan, you can use HSA and Employer will save $ 1,000.
On the other hand, E has a high deductible, so it is difficult to start insurance coverage, but once coverage starts, Co-insurance is 10%, so it is a relatively easy plan to pay for yourself. Even if the medical expenses are high, it is a plan that you only have to pay up to $ 9,000 at worst. Since it is a High Deductible Plan, you can use HSA and Employer will save $ 1,500. I don’t think it’s a good plan for doctors because I’m healthy, but if I’m sick or injured, I think it’s a good plan for people who want to reduce the burden as much as possible.
View Co-insurance
Co-insurance has already appeared in the story above, but it’s a reconfirmation. insurance is presented in% and you will be responsible. On the other hand, the first Co-payment that appears is displayed in dollars. It’s a similar word, but Co-payment is relatively easy to understand, and Co-insurance needs attention. The reason is that the former is specified as $ 20, $ 50, or $ 250 in absolute amount, and if you pay that amount, you will not have to pay the rest. Whether the total cost is $ 500 or $ 50,000, the insurance company will cover it * . On the other hand, Co-insurance is%, so the total amount can make a big difference between $ 500 and $ 50,000. For example, if the Co-insurance is 10%, the out-of-pocket cost will be a big difference of $ 50 or $ 5,000. If this is further Co-insurance of 30%, the out-of-pocket cost would be $ 150 or $ 15,000. % Is a habit. (* Sometimes, Co-payment is set, and there is also a combination type where Co-insurance is set in the part beyond that)
If possible, it is best to have a low Co-insurance and a low Out-of-pocket Maximum, but (1) Co-insurance is low and Out-of-pocket Maximum is high (Plan E), and (2) Co-insurance is high and Out-of- If the pocket maximum is low (Plan D), I’m wondering which one is better. Anyway, those with high Co-insurance and Out-of-pocket Maximum (Plan C) are high risk and should be avoided if possible.
It may be attractive that the HSA comes along and the Employer saves it, but I think it’s better to start by looking at the risk response level of the insurance plan itself, rather than looking at it first. ..
For example, let’s say you need surgery and it costs $ 30,000 for hospitalization, $ 30,000 for surgery, and $ 30,750 for 5 follow-up visits ($ 150 each). The cost for each plan is as follows. Is it a form of considering the risk level that you can tolerate by considering this, monthly insurance premiums, the presence or absence of HSA, etc.?
For A and B, $ 250 (hospitalization) + $ 0 (surgery) + $ 20×5 (outpatient) = $ 350 burden
For C, $ 500 (Deductible) + ($ 30,000- $ 500) x 30% + $ 150x5x30% = $ 15,575 => Out-of-pocket Maximum $ 7,600
For D, $ 1,400 (Deductible) + ($ 30,000- $ 1,400) x 20% + $ 150x5x20% = $ 7,270 => Out-of-pocket Maximum $ 4,000
For E, $ 2,200 (Deductible) + ($ 30,000- $ 2,200) x 10% + $ 150x5x10% = $ 5,050 => Out-of-pocket Maximum $ 4,500 burden
Monthly insurance premiums may be an important point, but the chart above does not dare to write insurance premiums. Rather than starting the comparison from the insurance premiums suddenly, I think it is better to pay attention to the insurance premiums after carefully considering the ease of getting medical services, the ease of maintaining health, and the compensation in case of illness or injury. increase. Also, plans that can be used with HSA are usually cheaper and you can get an Employer reserve, so I think it is a good deal, but once you get sick or injured, it can be a big expense, so what do you think about it? It’s a turning point in the decision.
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