Open Enrollment FAQs

At M A R Financial Group, we know how stressful the short open enrollment period can be for employees. Take a look at  these Frequently Asked Questions about open enrollment below and contact us to learn more about the types of coverage available to you.
 

Open Enrollment FAQs for the Employee

What is the difference between an HMO/PPO/EPO?

HMO: Health Maintenance Organization. Generally allows the lowest premium, participation in an HMO requires the patient to get a referral prior to seeing a specialist. HMO doctor networks also tend to be smaller.

PPO: Preferred Provider Organization. A PPO offers patients greater flexibility, but at a higher premium level. Participation in a PPO gives the patient the freedom to see any doctor – general or specialist – they wish, without requiring a referral.

EPO: Exclusive Provider Organization. Similar to a PPO with one major exception: EPO plans do not cover out-of-network charges.

What is an Individual deductible?

The Individual deductible is the amount, out of pocket, which you have to spend in order for the major medical benefits to kick in.

What is a Family deductible?

A Family deductible means that the medical plan will start to pay expenses after you and your family members have first paid out of pocket expenses that are equal to the family deductible amount shown on the rate sheet. Any combination of covered family members can be used to meet this deductible.

What is the difference between a co-pay vs. co-insurance?

Coinsurance is the percentage of eligible health care expenses the plan pays after you meet your required deductible. You are responsible for paying the remaining difference. Whereas a co-pay is a fixed dollar amount you pay for covered expenses.

What is an Out-of-Pocket maximum?

The maximum amount allowed by law in which you can spend on covered health expenses prior to the insurance plan covering 100% of the cost for covered items. Just as with deductibles, there are Individual Out-of-Pocket maximums and Family Out-Of-Pocket maximums.

I like that my health policies now have no pre-existing coverage limitations and maximum out-of-pocket expenses.

How to I ensure that this continues?

These protections are part of the Affordable Care Act, commonly known as Obamacare. So if you wish to have pre-existing condition coverage from day 1 and appreciate knowing there is a maximum amount you can spend on medical coverage, let your Congresspersons and Senators know that you support the ACA.

So… really… how does medical billing work?

Great question! There are four levels to how payments work with ACA plans:

A. Copays. You pay copays for regular doctor visits and other defined visits (OB-GYN, etc). Copays do NOT apply to your deductible.

B. Deductible. You break your arm, go to the hospital and have it set. Two things are at play here:

a. If in-network, you get a negotiated rate with the hospital.
b. You are responsible for the entire cost of the broken arm, up until you hit your deductible.

Once you hit your deductible…

C. Co-Insurance kicks in. You pay a percentage of the health coverage costs which accrue after you meet your deductible, until you hit…

D. Out-Of-Pocket maximum. Once you hit this, the policy pays 100% of all covered costs.

Sam has a policy with a $3,000 deductible, $7,000 max out of pocket, 80% co-insurance (insurance carrier pays 80%, Sam pays 20%). Gets into a car wreck, incurs $167,000 in medical bills for a 3-day hospital stay + 20 sessions of physical therapy regarding some shoulder separation and broken bones which occurred during the accident.
 

… The first $3,000 of those medical bills must come out of Sam’s pocket
  … Of the remaining $64,000, co-insurance applies: $64,000 X .20 = $12,800
  … HOWEVER, there is a $7,000 maximum out-of-pocket expense on his policy. Sam has already paid $3,000, so of the above $12,800, Sam owes $4,000 and the insurance company pays $8,800
  … And as Sam has hit the maximum out of pocket, the final accounting is Sam pays $7,000 and the insurance company pays $60,000. If Sam 

What is the value of the AFLAC Accident, Cancer, and other policies?

Voluntary Insurance such as AFLAC, group disability, and more, pays you or your beneficiaries a defined cash payment which can be used to pay deductibles, co-insurance, bills, living expenses, and more. They are a perfect complement to your health plans, especially those who selected a High Deductible plan.

Another way to think about it: Health insurance makes sure the doctor gets paid. The voluntary insurances make sure you get paid.

Sam has an AFLAC Accident policy (Option 2) and suffers through the above car wreck. He gets reimbursed, in cash, the following:

$1,000 – Initial hospitalization Benefit
$400 – Confinement Benefit ($200/day after first 18 hours)
$200 – ER X-Ray Benefit
$150 – Ground Ambulance Benefit
$150 – Imaging Benefit
$150 – Treatment Benefit ($25 per visit, max 6 visits)
$150 – PT Benefit ($25 per visit, max 6 visits)
$250 – Back Brace Benefit
$250 – Knee Scooter Benefit
$1,000 – Fracture Benefit (est)
$1,000 – Dislocation Benefit (est)
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$4,700