Need some co-insurance plan help

[njmomtoone]

Wondering if anyone has any experience with a health care plan that involved co-insurance (cost sharing). This is the first I have heard of this, but according to the health care rep, in 3 years this will be the norm.

Some background...we are both 37 and healthy (we go for all preventative care) and have one son, age 9 that is healthy.

We were told Friday, that my husband's health plan through his company is changing, June 1st. We are grateful that the company gives him $1000 per months towards insurance. I am not complaining, just confused as to what the best choice for us is. We have two options:

First, we can keep the current plan we have which is a Traditional EPO. $35 co-pay for doctors, $50 for specialists. The cost for us would go from price would $390 per month to $680 (our cost) which is a big jump.

Our second option is a EPO Cost Sharing Plan. Co payments are $30 for regular doctors and $50 for specialists. All preventative care is covered, no co-pay or co-insurance. If I read the materials correctly, if we take our son for a sick visit for strep, we may the $30 co-pay, but are responsible for a portin of the stret test itself? This plan is $180 per month, our cost.

Of course, this is alot to think about and we only have tomorrow. I couldn't ask any questions to the health care rep since it's a holiday weekend.

Any help you may have here would be greatly appreciated!

 

[tar heel]

Almost everyone I know has coinsurance plans now. I still have a flat fee for doctor offices, but pay a percentage of anything else. It's strictly percentage for my DH and kids (who are covered on his policy). We also both have to meet deductibles for procedures/diagnostic tests such as ct scans, xrays, ultrasounds, sleep studies, etc.

 

[Eastern]

It is difficult to give you advice because even within the same health insurance company, each plan is a bit different.

Generally, a high monthly payment will save you money on deductibles and co-insurance, but you have to consider the annual cost.

A lower monthly payment is attractive, but often comes with a higher deductible, higher out of pocket expenses (OOP) and higher coinsurances.

Is there a difference in your per person and family deductibles? What is your OOP (amount you must pay out per year before 100% coverage kicks in) for each plan?

A lower monthly payment is good if everyone is healthy. I have a son with more complicated medical problems, and so I must carefully consider my co-insurance, deductibles, and OOP each year when reviewing our plans.

Yes, I think you would owe a co-insurance on the strep test, and the office visit as well (a percentage of the amount that the company has contracted with the participating provider for). However, this is only a guess on my part. You really must speak with whomever administers your plan in order to receive accurate information.

Typically, you can change your plan once per year, on your anniversary date (in case you choose a plan and decide it does not fit your needs). Sometimes, they will allow you to upgrade (but not downgrade) at other times during the year. Again, you must speak with your plan administrator to get this information.

 

[pantherlj]

Look at your average doctor visits and RX for the last couple of years and see how much those visits would cost under each plan.

$500 a month difference is a lot of money - that would be a lot of doctor visits every month. You could "self fund" and take the $500 difference every month (the $680 in premiums vs the $180) and stick it in a savings account to cover any medical expenses you might have to pay.

 

[disfan07]

Our health insurance plan is a Premier PPO plan through my dad's company.

We have a :
Deductable- $250-Individual/$500-family
OOP max- $8000
Office visits- $20-primary/$40- specialist (does NOT count towards deductable)
Coinsurance- 80/20 until OOP met than 100%

So I will use myself as an example since I rack up the majority of the medical bills.
We pay everything until we spend $250 (not including deductables). After we spend $250 for myself, insurance kicks in and they pay 80% of everything and we pay 20% (doctors visits, tests, hospital stays, surgery, etc) until we spend $8000.
Once we hit the $8000 OOP max (which we do every year) we pay NOTHING except for the copays. Right now, until July 1st when our insurance year starts all over again, everytime I go to the doctors all we pay is the copay and we pay nothing for everything else I have done.

We've never had an insurance plan without a co-insurance and we have always had what is considered premier PPO plans.

 

[njmomtoone]

It is difficult to give you advice because even within the same health insurance company, each plan is a bit different.

Generally, a high monthly payment will save you money on deductibles and co-insurance, but you have to consider the annual cost.

A lower monthly payment is attractive, but often comes with a higher deductible, higher out of pocket expenses (OOP) and higher coinsurances.

Is there a difference in your per person and family deductibles? What is your OOP (amount you must pay out per year before 100% coverage kicks in) for each plan?

A lower monthly payment is good if everyone is healthy. I have a son with more complicated medical problems, and so I must carefully consider my co-insurance, deductibles, and OOP each year when reviewing our plans.

Yes, I think you would owe a co-insurance on the strep test, and the office visit as well (a percentage of the amount that the company has contracted with the participating provider for). However, this is only a guess on my part. You really must speak with whomever administers your plan in order to receive accurate information.

Typically, you can change your plan once per year, on your anniversary date (in case you choose a plan and decide it does not fit your needs). Sometimes, they will allow you to upgrade (but not downgrade) at other times during the year. Again, you must speak with your plan administrator to get this information.

Plan 1, the deductible is $1,000 per adult and $500 for my son. Plan 2 (more expensive) has no deductible.

I do have alot of questions for the plan admin and cannot speak to them until tomorrow..which is also when we have to make up our mind on a plan. I have a list of questions and will call first thing. I thought I would post here to get some opinions since this is the first I am hearing of co-insurance. It does get confusing.

 

[disfan07]

So basically it looks like for plan 2, the insurance kicks in automatically but you pay more per month.

It all depends on how much you use it. Higher premiums with less OOP expense plans are usually better for those who have high medical costs (like me).

Plans with lower premiums and more OOP expenses are usually better for famlies who rarely use medical services.

If you rarely use medical services, I would go with the lower premiums because the amount you pay a year even OOP would probably end up being less than paying higher premiums every year.

Have to say though, I had to look up what an EPO plan was. It looks like it is inbetween an HMO and a PPO plan type thing.

 

[njmomtoone]

So basically it looks like for plan 2, the insurance kicks in automatically but you pay more per month.

It all depends on how much you use it. Higher premiums with less OOP expense plans are usually better for those who have high medical costs (like me).

Plans with lower premiums and more OOP expenses are usually better for famlies who rarely use medical services.

If you rarely use medical services, I would go with the lower premiums because the amount you pay a year even OOP would probably end up being less than paying higher premiums every year.

Have to say though, I had to look up what an EPO plan was. It looks like it is inbetween an HMO and a PPO plan type thing.

The past 4 years we had an EPO plan.