Finances & Money

Choosing the Right Health Care Plan Option Four: The In Network Only Plan

Shawn, a subscriber and frequent commenter here at Clever Dude, as well as a personal friend of the Clever Dude and Dudette will be posting occasional guest articles. You can read his introduction here.

By Shawn

In my introduction post “Choosing the Right Health Care Plan“, I presented the health plan options my employer is offering this year, some of my own life issues and assumptions, and some definitions of terms I’ll be using in this series.

The plan for this series is to allow you, the reader, the chance to see into the calculations and decision process I’ve taken to decide the best health plan from my employer based on my own parameters. You can use this series as a basis for your own calculations and decision, but keep in mind our lives and life issues are uniquely different. This article will focus on the fourth plan: In-Network-Only, with No Deductible.

Option Four: In-Network-Only, No Deductible Plan

I was hesitant to even look at this plan because it offers no out-of-network benefits. This means, that if we were to go to a doctor that does not accept our insurance, we would be responsible for 100% of the cost of the service. The three previous plans had coverage for out-of-network services that required a larger co-pay.

However, all of our doctors are in-network, and all of the hospitals in the area are in-network. My only concern was if we needed emergency care while traveling. I spoke with an associate at the company and learned that, even though there are no out-of-network benefits, should we need to go to an out-of-network emergency room, we would be covered in-network. However, if we needed to be admitted to an out-of-network hospital, we would need to obtain a pre-authorization to do so. In this case, we would pay our normal in-network co-pay, and the insurance company would pay their portion of their negotiated rate. We would be responsible for the difference in the hospital’s actual cost versus the negotiated cost.

Any expenses related to an out-of-network claim would not count towards our annual out-of-pocket maximums.

I did a little searching, and it turns out that the hospitals in the areas we visit most often are in-network (remember, I’m a klutz). With that reassurance, I decided to take this plan into consideration for the year.

With this plan, I would pay a monthly premium of $62 for myself, $102 to cover my wife and $51 to cover our child. This works out to a premium cost of $3,204 for the year.

There is no deductible for this plan while the out-of-pocket maximums are $4,811.00 per individual and $8,660 per family. These are considerably higher than the out-of-pocket maximums for the No Deductible Plan.

Unlike the three previous options, the co-pays for most services are flat fees, rather than a percentage of the cost. In this plan, maternity care is covered at 100%, an inpatient hospital stay has a co-pay of $449 and an ER visit has a co-pay of $96.

Working with the assumptions from the Introduction article, the negotiated cost of the OB services is around $2,500. Since maternity care is covered at 100% in this plan, we would not have to pay a co-pay for this service.

For a normal delivery, the negotiated costs for mom would be around $2,973. Since this would be considered an inpatient hospital stay, our co-pay would be $449. For the baby, the total negotiated cost is around $1,080. This would also result in a co-pay of $449.

For a C-Section delivery, the co-pays would stay exactly the same!

For my assumed ER visit, the negotiated cost is around $4,000. Of this, I would only have to pay $96.

Our Total Costs on the In Network Only Plan

With my assumptions, here’s the break down of the total cost for this plan for the year

  • $3,204 for the premium
  • $994 for co-pays
  • $0 for deductibles

Making the total cost of this plan $4,198 out of the maximum of $11,864 possible for the plan. That maximum total accounts for the premiums plus the out-of-pocket maximum for the family.

This gives us the cheapest of the four plans in assumed out-of-pocket expense, by at least $1,000.

In my summary article, I’ll explain the choice I made (it’s not as easy as you would have expected).

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