I'm insured under my company's health insurance. I'm under the family plan (Allegiance OAP Gold). Everything will be assumed to be In-Network.
Deductible: $3,000
Out-of-Pocket: $7,000
On the Allegiance website, I can see there's a section for Medical Deductible and for Medical Out-of-Pocket. Are these the same as the overall deductible?
Also on the Allegiance website, under the Medical OoP (Out-of-Pocket) section, I see there's a specific amount I used and an amount my family used. If I signed up for their family plan, why would it track my individual spending, as well as list an individual OoP amount?
This may answer my second question, but if I meet the individual deductible/OoP before the family dedictible/OoP is met, does that mean the insurance company will start covering their amounts, if the plan calls for it?
If I reach my maximum OoP, the insurance company will cover the costs of everything for the rest of the year, including childbirth? I'm making sure I fully understand the information from this website (should link to the Jane example).
Lastly, if my wife happens to be pregnant and gives birth while we haven't met our deductible/OoP, will the amount I owe be applied towards the deductible/OoP and the insurance company will cover (in my case) the remaining 80%?
Sorry for all the questions, I'm bracing myself for a possible childbirth this year and don't understand much with health insurance. Thank you to whoever may be able to answer any of my questions.
Unless your plan has a separate Ded/OOPM for pharmacy or other services (rare, but it happens) you can assume it's all care- medical and pharmacy.
You have to check and see if the family deductible is aggregate or embedded. Aggregate means you have to meet the full Family Deductible/OOPM in full. Embedded means one person can meet the plan's individual Ded/OOPM individually, even if the family doesn't meet the family ded/oopm as a whole- https://chirblog.org/embedded-deductibles-and-how-they-work/
Assuming it's an embedded deductible, yes- once one person meets his or her individual deductible, that person will move to co-insurance, even if the full family deductible isn't met yet. If the deductible is aggregate, you'd have to meet the full family deductible.
Assuming it's embedded out of pocket max, yes- once one person meets his or her individual oopm, the plan will pick up 100% of all medically necessary, non excluded, in network care for the rest of the plan year for that individual. Including child birth.
You are correct in practice. You will have to check your plan details--- but in general, copays apply to the out of pocket maximum amount, but not deductible. All other payments (coinsurance or full contracted rates if it's a HDHP) will apply to both the deductible and Out of Pocket Max.
You can rest assured that the most you will pay for medically necessary, in network, non excluded care for the year is $7000+ your monthly premiums. Anything above that, the plan will pick up at 100%
