Transcript Deductibles and maximums

Deductibles &
Maximum out of
pockets
Part of the Medical Plan
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Definitions
Deductible: An amount you pay
(once each year) BEFORE the
insurance kicks in
For example, if you experience a $20,000 hospital
stay and you have a $1500 deductible, you will
need to pay the first $1500 of that charge
before co-insurance begins to apply
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Definitions – cont.
Co-insurance: After the deductible
is met, you and the insurance
company share in the payments
For example, if the unpaid balance AFTER your
deductible is $18,500, the insurance plan will
pay 90% of the balance and you pay 10%
(assuming you are in-network). This continues
until you hit your maximum out-of-pocket.
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Definitions – cont.
Maximum out-of-pocket: A dollar
limit on the most you have to pay
in a calendar year.
For example, if your Maximum out-of-pocket is
$3000, once you have paid $3000 for
deductible and co-insurance, the insurance
plan kicks in and pays 100% of covered
charges for the balance of that calendar year.
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Definitions – cont.
Illustrating total charges of $50,000
With no Max out-of-pocket
You pay
Insurance pays
Deductible
Co-insurance
Additional expenses
$1,500
4,750
10%
$43,750
90%
With Max out-of-pocket
Deductible
Co-insurance
Additional expenses
$1,500
1,500
0%
$47,000
100%
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Definitions – cont.
In-network: Your portion (co-insurance) is
10% if your service is within the CMH PHO
30% if in the United Healthcare Options PPO
50% if outside both of these networks.
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Definitions – cont.
The CMH PHO consists of
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CMMC, Lewiston
Bridgton Hospital
Rumford Hospital
Parkview Hospital, Brunswick
Franklin Memorial , Farmington
Access the listing at “Find a
doctor” at www.cmmc.org
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Definitions – cont.
The United Healthcare Options PPO consists
of healthcare providers who have
contracted with UHC to accept payments
as submitted (won’t balance bill the
patient). Typically they also offer their
patients a negotiated discount.
http://www.umr.com/oss/cms/UMR
/Options_PPO_Exclusions.html
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Definitions – cont.
Premiums: The amount paid by CMH and
by employees to provide coverage.
Overall, CMH pays nearly 75% of the
total premiums on Medical Insurance
As you review your options and “do the math” for
which coverage makes the most sense for you
and your dependents, realize you are seeing
only a fraction of the total cost for coverage.
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Definitions – cont.
Pre-tax premiums: The federal government
allows premiums to come out before FICA,
Medicare, federal and state deductions.
Your actual cost is really close to ¾ of what
you see as a deduction. So a $200
deduction really “costs” you about $150.
For those covering domestic partners, remember the
portion of the premium that represents your partner’s
coverage must be taken as an after tax deduction.
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What are the deductible levels?
There are two different deductible levels and
each has an in-network and out-of-network
amount. The individual deductibles are:
CMH PHO
UHC Options PPO
Outside both
(10% co-ins.)
(30% co-ins.)
(50% co-ins.)
Lower deductible
$ 500
$1000
$1000
Higher deductible
$1500
$3000
$3000
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Is there a family deductible?
Yes, there is protection for three or more people on
the same contract that prevents each person from
having to meet the full (individual) deductible. The
family deductible information is:
Family Ded.
CMH PHO
(10% co-ins)
Family Ded.
UHC Options PPO
(30% co-ins)
Family Ded.
Outside both
(50% co-ins)
Lower
deductible
$1000
$2000
$2000
Higher
deductible
$3000
$6000
$6000
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What are the Maximum
out-of-pocket limits?
Individual Maximum out-of-pocket limits are:
CMH PHO
UHC Options PPO
Outside both
(10% co-ins.)
(30% co-ins.)
(50% co-ins.)
Lower deductible
$2000
$4000
$4000
Higher deductible
$3000
$6000
$6000
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Is there a family Maximum
out-of-pocket limit?
Family maximum out-of-pocket limits are:
Family MOOP
CMH PHO
(10% co-ins)
Family MOOP
UHC Options PPO
(30% co-ins)
Family MOOP
Outside both
(50% co-ins)
Lower
deductible
$4,000
$8,000
$8,000
Higher
deductible
$6,000
$12,000
$12,000
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