Get smart on the new medical plans.
The New Year is under way, and chances are you’re already making the most of the medical plan you chose during Open Enrollment. But just to make sure you’re up to speed with our new plans, let’s take a minute to review the most important features, so you can spend the rest of the year healthy and informed.
Office Visits: We have kept the copay concept for office visits that were available from the previous plans. Under the Basic or Enhanced PPO, if you visit a general practitioner (generally, a primary care physician, pediatrician, or internist), you pay a copay of $20. The copay for visits to a specialist is $40.
Deductible: A deductible is the amount you or your covered dependent has to pay each year before the medical plan begins to pay for the benefits it covers. Generally, any medical service received outside of the doctor’s office is subject to the deductible (and coinsurance). The way it works is that you (or your covered dependent) pay the deductible, and then your plan pays for covered items at the right percentage of the cost.
Out-of-Pocket Maximum: This is the limit on the amount you spend in a calendar year for covered medical expenses in copays, deductibles and coinsurance, after which the plan reimburses eligible medical expenses at 100%.
Let’s look at an example.
Say we have John and Sheila:
John is enrolled in the Enhanced PPO and he covers his wife, Sheila and their two children, Sam and Dave. After a visit to his primary care physician (PCP) and three visits to his cardiologist, it is determined that John needs to have surgery costing $10,500. After surgery, he will need six physical therapy sessions. John’s individual annual out-of-pocket maximum in the Enhanced PPO is $1,500.
Below is the breakdown of what John will have to pay
John pays $140
(one copay of $20 to his PCP and 3 times $40, the copay for each visit to the specialist)
John pays $1,320
($300 deductible + $1,020, 10% of the remaining cost)
$10,500 – $300 (Deductible) = $10,200
$10,200 x .10 (10% coinsurance) = $1,020
John should pay $240
(6 x $40, the copay),
but only has to pay $40
This is because the sum of what he’s already paid is $1,460 ($140 + $300 + $1,020) so he only needs to pay out an additional $40 — the cost of one office visit —
to meet his annual out-of-pocket maximum of $1,500.