Shuffler, I checked out that site that was a killer. I didnt get to add my wife is type 1 diabetic, but I found a plan for 530 a month and 500 individual/1000 family deductible so that sounds good.
It says out of pocket max is $5,250 for an individual and $10,500 for a family. Does anyone know what that means? I just put my wife and I into the application and those are the numbers it said. Thanks
Off the top of my head, so please double check, but ...
You need to know the ways in which you end up paying for health insurance.
Premiums - You pay this monthly, whether you receive any healthcare or not. This is the $530/mo number you found.
Deductible - You pay the full cost of all healthcare you receive until you reach your deductible. Insurance won't help out until you've fully paid this amount. This is the $500/$1000 number you found.
Co-Pay - After you reach your deductible, that's when the insurance company starts kicking in. But how much do they pay? In most plans (even plans with employers, and not on the ACA) this is a % of the cost of the healthcare. In the case of the ACA, the "metal" type of the plan determines the %. In a bronze plan, the insurance will pay 70% of the cost. Silver is 80%. Gold is 90%. So if you got a $1000 bill on a silver plan, you'd pay $200 and the insurance provider would pay $800.
Max OOP - This is when you've finally stopped paying. When the amount you've paid in deductibles and co-pays reaches the Max-OOP, then the insurance provider pays the full cost of any further charges (until next year).
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So, let's suppose the plan you're referencing above is a silver plan.
You'd start by paying $530/mo, each month for the year. So that'd be $530 * 12 = $6360.
Now suppose you had a $800 medical bill, you'd pay the first $500 as deductible, and then (because it's a silver plan) 20% of the remaining $300.
$500 + (0.2 * $300) = $560
Now suppose your spouse had a surgery for $20,000.
You'd first pay her $500 deductible.
Then (because it's a silver plan) you'd pay 20% of the remaining $19,500 = $3,900.
Uh oh! The surgery required a follow-up for another $10,000.
You would've paid 20% of $10,000 = $2,000 ... except that would make $3,900 + $2,000 = $5,900, which is greater than the $5,250 individual Max OOP.
So instead you just pay $1,350 to bring your full payments for the year up to the $5,250 individual max OOP. ($3,900 + $1,350 = $5,250)
Even though your spouse has hit their individual max OOP, you still haven't.
So when you go see the doctor for $200, you're still paying 20% * $200 = $40.
