S/O - Deductible/Out of Pocket Insurance Question - Update: Question Answered

[Kassia]

If an individual's healthcare expenses exceed the family out of pocket limit does that mean everyone else's expenses are covered for the rest of the year?  

 

For example, our individual deductible is $6500 and family out of pocket is $13,000.  My medical expenses will exceed $13,000.  So, can DH have tests done now and not have to pay or does he have to fulfill his individual deductible first?  

 

ETA:  I'm embarrassed since the answer seems obvious now! 

 

 

Edited July 27, 2017 by Erica H

[historically accurate]

We have an individual out-of-pocket that can be hit and then a family out-of-pocket. If one person hits the individual out-of-pocket amount, there are no more bills for them. But the next person will pay for theirs. Ours is 4000 individual/12000 family. So in your case, on my insurance, you would be charged 4000 for your expenses. Your husband (or the rest of the family together) would have 8000 in expenses before you would be done with medical expenses for the year.

 

It sounds like your insurance may only have a family out of pocket, so anything after your expenses would be covered. I'd definitely double check because there are so many different ways to structure insurance.

[PuddleJumper1]

Ours works this way - we have $2500 individual and $5000 family. When one person reaches their $2500 mark all of their expenses are covered for the rest of the year. In order to meet the family amount other family members have to meet part or all of theirs. Once the $5000 is met then everything for everyone is covered. We have 5 people on the insurance. It doesn't matter how much we each pay out of pocket as long as the total reaches $5000 but no one person is counted for more than $2500.

 

That's how our particular policy works.

Edited July 27, 2017 by PuddleJumper1

[QueenCat]

If an individual's healthcare expenses exceed the family out of pocket limit does that mean everyone else's expenses are covered for the rest of the year?  

 

For example, our individual deductible is $6500 and family out of pocket is $13,000.  My medical expenses will exceed $13,000.  So, can DH have tests done now and not have to pay or does he have to fulfill his individual deductible first?  

 

It does with ours. We no longer have an ind. deduct but when we did, it was part of the family deduct so once the family deduct was met, the individual deduct no longer mattered. But what is your family deduct? That is not the same thing as your family out of pocket. Our family deductible is $2600 (odd number because you can do certain healthy things to reduce it). Our family out of pocket is $6000. Once we hit the $6000, everything is covered at 100%.

[Kassia]

I checked and our deductible is $4600 Individual/ 9200 family

 

Out of pocket maximum is $6500 individual/ 13,000 family

 

 

 

My OOP expenses will be well above $13,000 (the family OOP max), but does that mean only my expenses are covered for the rest of the year or everyone on our family plan?  

 

ETA - looks like, from most of the responses, that I can incur more expenses and they will be covered, but anyone else in the family has to meet their individual deductible first.  

 

 

Edited July 27, 2017 by Erica H

[QueenCat]

I checked and our deductible is $4600 Individual/ 9200 family

 

Out of pocket maximum is $6500 individual/ 13,000 family

 

 

 

My OOP expenses will be well above $13,000 (the family OOP max), but does that mean only my expenses are covered for the rest of the year or everyone on our family plan?  

 

How can your OOP be over $13,000 if the individual OOP is $6500? You shouldn't be paying more than the $6500.

[Kassia]

How can your OOP be over $13,000 if the individual OOP is $6500? You shouldn't be paying more than the $6500.

 

Good point.  I hadn't even thought of that.  I guess that answers my question right there!   :o

[G5052]

You may also have an in-network OOP and out-of-network OOP that work differently. I realize that some people don't even have out-of-network benefits.

 

The in-network counts what you pay.

 

They handle the out-of-network differently for us. They use a formula and count what their estimate is of what you would have paid if they were in-network. So if the out-of-network hospital charges $10,000, and they pay the hospital only what they would have if it was in-network, say $1,000. They would estimate that you would owe $500. So you are billed $9,000 by the hospital and only $500 goes on your out-of-network amount. 

 

We've run into some out-of-network providers who won't bill the full amount of what insurance wouldn't pay. One test that three of us have had costs $2,600+ out-of-network with insurance only paying a few hundred dollars, but they only charge $260 after insurance pays. DD also went to a surgical center like that. They aren't in any insurance networks, but told me a base rate we'd pay if it was a routine surgery. Insurance paid the in-network amount, and we paid just slightly more than I was quoted because it took a little longer than expected.

 

That may not apply here, but it's good information to know if it does.

Edited July 27, 2017 by G5052

[regentrude]

How can your OOP be over $13,000 if the individual OOP is $6500? You shouldn't be paying more than the $6500.

 

This. That's the whole point of an individual OOP maximum.

[scholastica]

There's the deductible and then there's the OOP Max, Out of pocket maximum is all the stuff you can still have to pay after the deductible, like copays and coinsurance. Most plans have you pay a copay or a percentage of expenses after you reach the deductible until you reach the OOP Max. That's why they're different numbers.

[Supertechmom]

NOt an obvious  answer as I can't get anyone  to explain it to me either and that includes friends who work for the insurance company

 

 I have more people on the plan than the family deductible limit.  So  each person has to meet the deductible? Yes....but does that mean>....

 

5 people each with 750 deductible, family max of 2250..   So I will pay 3750 total in deductibles before we get to 10% pay for everyone even though that is more than the family max???? Each person must hit the 750 even if we max the family total max of 2250?  So right now two people have hit individual deductibles and are now at the 10% pay point.  Another 350 and I will max the family total. But will I still have to pay 1500 more for those that didn't met their individual deductible?  I can't get anyone in insurance to say yes or no.....

 

On my benefit page, Everyone's family deductible remaining has the same amount while their individual is all different amounts.  The out of pocket is the same deal.  The individual's are different but the family number is the same.   when I max the family deductible, will everyone's remaining individual amount then be zero?

 

My family out of pocket is 6,000.  My per individual is 2,000.    5 people would equal a total individual of 10,000.  Do I stop paying after 6,000 or after 10,000?

 

I'm making this more confusing than it needs to be  but the math doesn't add up so it confuses me.   And the service rep just kept repeating your max is 6,000. I know but  the statement remaining amounts leads me to believe otherwise.....Unless they magically wave a wand and change the numbers.  

 

I'm trying to decide if I should have a procedure this year or eat the cost in Jan and have next year be a freebie year for the most part as it would max out both individual and family and the out of pocket max in one big ole swoop........

[TravelingChris]

Supertechmom.  in your case, only three people would have to meet the deductible- the other two would not and after the first three met their deductible, the other two would only have to pay co-pays like the first three.  But if they used any medical services before the three met their deductible, they would be tryng to meet the deductible too.  On the OOP, the minute any or some of your expenses that are allowable hit 6000, no other expenses would need to be paid by anyone.