Having trouble understanding some health insurance stuff.

[fuzzybabybunny]

I'm reading their plan book and I want to make sure I'm getting the terms right.

1. Annual Medical Deductible: say, $900. This is the amount I have to shell out before the insurance starts to pay for anything beyond the basic, preventative office visits, and drug prescriptions, right? For anything more, like an ER visit, physical therapy, surgery, etc I have to first pay my insurance company $900 right?

2. Annual Out of Pocket Maximum: say, $3,900. This is the max amount that I can expect to pay a year for anything, right? I got into an accident that's $1,700 for the ambulance ride and $31,000 for the ER visit, so a total of $32,700. Insurance says for ER and Ambulance, I'm responsible for 40%, so 40% of $32,700 is $13,080. But since the OOP Maximum is only $3,900, all I have to end up paying is $3,900, right? The $3,900 already includes that $900 deductible.

3. My monthly rates. Rates I pay just to have the privilege of having this health plan ($125/month). Anything past the routine exams I have to shell out $900 in deductible for.

 

[Jumpem]

Your $900 deductible is what you have to pay on the first $900 of care. Regardless of the type of visit.

Usually the out of pocket maximum and deductible are separate ($900 + $3900 = $4800).

 

[Gibson486]

I'm reading their plan book and I want to make sure I'm getting the terms right.

1. Annual Medical Deductible: say, $900. This is the amount I have to shell out before the insurance starts to pay for anything beyond the basic, preventative office visits, and drug prescriptions, right? For anything more, like an ER visit, physical therapy, surgery, etc I have to first pay my insurance company $900 right?

2. Annual Out of Pocket Maximum: say, $3,900. This is the max amount that I can expect to pay a year for anything, right? I got into an accident that's $1,700 for the ambulance ride and $31,000 for the ER visit, so a total of $32,700. Insurance says for ER and Ambulance, I'm responsible for 40%, so 40% of $32,700 is $13,080. But since the OOP Maximum is only $3,900, all I have to end up paying is $3,900, right? The $3,900 already includes that $900 deductible.

3. My monthly rates. Rates I pay just to have the privilege of having this health plan ($125/month). Anything past the routine exams I have to shell out $900 in deductible for.

1. Depends, do co pays go towards your deductible?

2.For this, yeah, but should co-pays count towards this (but depends on plan, again). Basically, it's the most you will be liable for.

3. depends on your plan...but I am not sure what you are asking

 

[guyver01]

1. Annual Medical Deductible:

Its how much you have to pay every year before the insurance starts to pay at all. So, If you have a $500 deductible, you have to pay for all your doctor visits and medication until you spend $500. After that the insurance will kick in and you just pay your co-pay when you go to the doctor.

2. Annual Out of Pocket Maximum:

The yearly out-of-pocket maximum is the highest or total amount your health insurance company requires you to pay towards the cost of your health care.

Out-of-pocket expenses are what you pay for health-related services above and beyond your monthly premium. Depending on your health plan, these expenses may include an annual deductable, coinsurance, and copayments for doctor visits and prescription drugs.

3. My monthly rates. Rates I pay just to have the privilege of having this health plan ($125/month).
YES

see answers in bold above