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Gary | Does one have to pay the full out of pocket maximum each year? |
I'm looking to buy health insurance from Kaiser and so it says that their family plan annual out-of-pocket maximum (individual/family) is $2,500/$5,000. Am I supposed to pay the full amount of that maximum each year or do I only pay partial depending on how much service I get? Is that amount on top of the monthly rate that I have to pay to buy the insurance? Also when they say "individual/family", does that mean it's $2,500 for the subscriber plus $5,000 for each family member? |
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mbrcatz
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Yes, the deductible and out of pocket maximum reset every year. Yes, they are on top of the monthly amount you pay for premium.
The $2500/$5K means, the MOST you have to pay for one person, is $2500, but if you have a really bad year, and four people need surgery, the most you need to pay for the entire family, is $5,000. |
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Scott C
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Here is how it "should" work (I say should because I don't work for Kaiser, but it should be standard from company to company)
If you are single, you need to pay $2,500 in out of pocket costs before they will pick up the rest of the benefit. This could include deductibles, coinsurance, and copays. It's a cumulative cost as the year goes on, but yes, the amount resets yearly.
Regarding the individual/family. Typically, it can be read as $2,500 per person, not to exceed $5,000 for a family ~or~ if you are in a family, the dollar amount changes to $5,000 for everyone. It's hard to say exactly without seeing the whole benefit summary from the insurer.
If you can provide what type of plan you will be getting or some more details I can help you further. (i.e. is it an HSA vs. HRA vs. PPO) |
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Flower
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I never heard of an annual deductible for Kaiser. Maybe things have changed. You have monthly premiums and co-payments for services depending on which plan you choose. You should call Member Benefits and ask about this. |
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efflandt
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Maybe not clear is that you only pay up to $2500 per family member or $5000 total if you have actual medical expenses up to that amount or more. You do not pay that if you have no medical expenses in a year. |
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StephenWeinstein
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No.
1. The "out of pocket maximum" is the most that you might have to pay in any year. You may have to pay less, depending on the amount of service received.
2. "individual/family" and "$2,500/$5,000" means $2,500 for each person ($2,500 for subscriber and $2,500 for each family member) and $5,000 total for everyone (subscribers and family members, together). You would not have to pay more than $2,500 for any one person, and might have to pay less. Even if there are more than two individuals, you would not have to pay more than $5,000 total.
Note: The out of pocket maximum refers only to copays, deductible, coinsurance, etc. It does not include the premium, any charges for services that are not covered by your insurance, or out-of-network bills that are not "reasonable and customary". |
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