Question:

Would someone explain the deductible/OOP?

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Plan Benefit Summary OneDeductible PPO Elite

Monthly Premium 139.90

Deductible Benefit Summary

2,850

Office Copay No

Coinsurance / Maximum Out-of-Pocket 80% (OOP: $2,000)

Lifetime Maximum 25Mil

PPO Network HLK - www.healthlink.com

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To customize this plan with a different PPO network call us at 866.425.3341

Maternity Coverage No Coverage

Outpatient Maximum

HSA Ready Yes

Plan Description The high deductible health plan with a single deductible for the whole family

Preventive Care / Wellness / Routine Physical Subject to the integrated deductible and plan coinsurance. Benefits for preventive medicine services are limited to a maximum calendar year benefit of $1,500 per covered person. The maximum will not apply to routine mammograms, routine pap tests, routine annual prostate specific antigen (PSA) tests, the annual exam for detection of prostate cancer, child screening tests and diagnostic follow up care for hearing loss, and child immunizations. Child immunizations are exempt from any deductible, copayment and/or coinsurance provisions. Child screening tests and diagnostic follow up for hearing loss are exempt from any deductible. If the Optional First Dollar Preventive Services Benefit is purchased (where available), the plan deductible and coinsurance will be waived for the first $500 of covered services performed by a participating provider for each covered person per calendar year after a 12-month benefit waiting period.

Doctor's Office Visits Subject to the integrated deductible and coinsurance.

Outpatient Lab Tests & X-rays Subject to the integrated deductible and coinsurance.

Outpatient Surgical Subject to the integrated deductible and coinsurance.

Prescription Drugs Subject to the integrated deductible and coinsurance.

Inpatient Services / Hospitalization Subject to the integrated deductible and coinsurance.

Emergency Room Services Covered charges are subject to the integrated deductible and coinsurance.

Ambulance Services Professional ground or air transportation in an ambulance for a covered person who needs emergency treatment for a sickness or an injury to the nearest acute medical facility that can treat the sickness or injury. The ambulance service must meet all applicable state licensing requirements. Subject to the integrated deductible and plan coinsurance.

Rehabilitation Services Inpatient: subject to the integrated deductible and coinsurance. Benefits are limited to a maximum calendar year benefit of 90 days per covered person. Outpatient: subject to the integrated deductible and coinsurance. Benefits are limited to an outpatient physical medicine services maximum calendar year benefit of $3,000 per covered person. Outpatient physical medicine services (rehabilitation services) include benefits for chiropractic care.

Chiropractic Services Subject to the integrated deductible and coinsurance. Benefits are included in the outpatient physical medicine provision which has a combined calendar year maximum of $3,000 per covered person.

Mental Nervous / Substance Abuse Subject to the integrated deductible and 50% coinsurance for participating providers, 70% coinsurance for non-participating providers. $2,500 calendar year maximum.

Complications of Pregnancy Covered charges are covered the same as any other illness.

Calendar Year Maximum None.

Plan Exclusions Exclusions consist of the following, but are not limited to: illness or injury caused by war (whether declared or undeclared), commission of a felony, attempted suicide, influence of an illegal substance, or a hazardous activity for which compensation is received; routine hearing care, vision care, surgery to correct vision, routine foot care or foot orthotics, except for podiatric appliances for the prevention of complications associated with diabetes; cosmetic services; routine dental care unless the dental insurance option is chosen; diagnosis and treatment of infertility; maternity and routine nursery charges unless the maternity option is chosen; growth hormone stimulation to promote or delay growth; genetic testing, counseling and services; charges to treat sexual dysfunction or inadequacy or to restore or enhance sexual performance or desire; over-the-counter products; charges related to "quality of life" or "lifestyle" concerns including, but not limited to: smoking cessation, obesity, hair loss, or cognitive enhancement; charges incurred due to a pre-existing condition until you have been continuously insured for 12 months (unless the condition has been specifically excluded from coverage).

Pre-Existing Condition

A Sickness or an Injury and related complications:

1. For which medical advice, diagnosis, care or treatment was sought, received or recommended from a provider or Prescription Drugs were prescribed during the 12-month period immediately prior to the Covered Person's Effective Date, regardless of whether the condition was diagnosed, misdiagnosed or not diagnosed; or

2. That produced symptoms during the 12-month period immediately prior to the Covered Person's Effective Date which reasonably should have caused or would have caused an ordinarily prudent person to seek diagnosis or treatment.

A pregnancy that exists on the day before the Covered Person's Effective Date will be considered a Pre-Existing Condition, subject to the Pre-Existing Condition definition. DEF: 500.002.TX

These rates are only valid for policies issued with effective dates from 5/1/2008 to 5/28/2008. Rates quoted for more than 30 days in advance of the effective date are subject to change and are not guaranteed. This proposal is not an insurance contract. Only the actual contract provisions will apply. Final rates may vary slightly due to the rounding process. The effective date on the quote does not guarantee coverage and is subject to change. The preferred rates are subject to final underwriting approval. Applicants may be subject to a pre-existing condition limitation on benefits. Refer to the certificate of insurance for terms and conditions.

For applicants under age 40, to qualify for preferred rates, cholesterol readings, if known, must be under 220 and blood pressure readings, if known, must be under 140/90 bp.

Preferred rates are not available to every customer. Generally, you must be in good health in order to receive the preferred rate. These rates are determined and subject to change based upon your application and medical history, our underwriting requirements, and any additional benefits you may select.

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3 ANSWERS


  1. Well done by Christine R.

    You also need to know this plan is a Qualified High Deductible Health Plan which makes it HSA compatible. That means you can open a Health Savings Account  and deposit up to $2,850 each year. The deposit is written off your taxes just like an IRA. If you spend the money on qualified expenses the account remains tax free. If you don't spend the money it remains in the account for future use.  Qualified expenses include the decutible, dental, vision over the counter medications, etc.

    This plan has a lifetime benefit of $25 million most other individual plans cap at $5 million

    Michael,

    The HAS's actually cost me ( the broker) money. High deductible plans have lower premiums which = lower commission.

    The HSA bank account provides no benefit to the broker/agent and saves the insured hundreds if not thousands over traditional plans. I suggest you learn about HAS plans if you are going to comment on them. I woul dbe glad to run you a quote you can use to compare to health link.

    http://www.hsainsider.com/


  2. Here we go...

    You are responsible to pay the first $2850 of your covered medical expenses. This includes the cost of a doctor's office visit, prescriptions, an ER visit, etc. After that, the insurance company will cover 80% and you cover 20% until you've paid another $2,000 out of pocket. At that point, the plan will pay at 100%.

    So, if you are in a car accident, spend a week in the hospital, and rack up $30,000 in medical bills, you will pay $4850 out of pocket. All of your doctors visits, prescriptions, etc for the rest of the year will be at no cost to you.

    If , on the other hand, you have a couple of doctors visits, a specialist visit or two, and routine lab work over the course of the year, you will likely not meet your deductible and the plan will pay nothing. The deductible is annual so if you have $2800 in costs every year for ten years, the plan still would have paid for nothing.

    It is important to note here that the deductible, co-insurance, and out-of-pocket max are all for covered expenses. If you go for routine accupuncture or something like that, none of the money you pay there will count into the deductible, etc.

    The only things that will be covered before you meet the deductible are those items specifically listed as being exempted from the deductible (like children's immunizations).

  3. You know what... never believe those HSA stuff.. they are just trying to make a profit out of it.... you are here asking the difference not about looking for a policy...anyway,

    DEDUCTIBLE

    this is an amount that needs to be satisfied before we pay for a certain percentage....

    Example. your deductible hasnt been satisfied yet , and once you render a procedure lets say surgery, this will be sent to the insurance and the insurance will apply them to the deductible.... once the deductible has been met.. let say your insurance is 80 / 20, meaning insurance will cover 80 percent of the allowable amount and 20 percent will be your responsibility. once deductible has been met then insurance will cover 80 percent and you will only pay 20 percent....

    OUT OF POCKET (OOP)

    this is an amount where once  you reach that amount , the insurance will cover 100 percent of the allowable amount... that means that you will never pay anything or the 80/20 will not apply any more since OOP has been met....

    check out some procedures because there are some procedures where deduct / and OOP doesnt apply....

    HEALTHLINK AGENT

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