Don't Write Much Health, Need Help Sorting Out a Quote.

[roger_lockless]

Aside from Long-Term Care Insurance, I've not worked much with Health Insurance policies, but someone I know came to me in search of a policy and I'm trying to help her out. I got her some quotes for her family of 4, but a couple things aren't clear to me, and I'm not getting calls back from the insurance company or marketing center that put the quotes together fast enough for my liking. Hopefully one of you Health guys can sort me out.

I'm looking at a PPO plan with the following In-Network statistics:

Deductible: $3,000
Family Limit: $6,000
OOP Max - Single: $5,500
OOP Max - Family: $11,000
Lifetime max Medical: $1,000,000

My questions are:

(1) Bearing in mind that all plans are different, would it be reasonable of me to think that the Lifetime Max is $1,000,000 for EACH of the 4 family members, or is it a total for the whole family?

(2) Why are the OOP amounts different than the individual/family deductible amounts? Isn't a deductible essentially an OOP Max? I would think those would read $3K and $6K respectively, just like the deductibles. At first I thought it was an error, but some of the other company's had the same incongruity. Can anyone explain this to me?

 

[DS4]

1) Usually lifetime max is" per insured, per lifetime".
2) I'm assuming this is not a HSA compatible plan? Usually, after the deductible, there is coinsurance of 80/20, 70/30, etc.

Is the deductible included in the OOP max? The benefit summary will answer your questions.

What health ins co? What state?

 

[Jeff0673]

What companies are you working with? I work with a broker benefitmall.com and you can run quotes for almost every company in that state, and the staff will help you through the whole process. I use them in TX and CA

 

[Dandy1]

The lifetime max issue goes away pretty quickly. If the plan wasn't written prior to March 23, it can't be grandfathered, so the lifetime max has to be eliminated September 23.

Many carriers do not count deductible towards OOP.

 

[DS4]

Many carriers do not count deductible towards OOP.

That is why I "assumed" the quote did not represent a HSA compatible plan.

 

[AllenChicago]

You should also learn how important "Wellness" benefits are to your potential client. More policies are starting to offer free Mammograms, Gynecological exams, Annual Physicals, and are only charging a small Co-Pay for X-Rays & Blood Tests.

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[Northeast Agent]

Rob Ravis said:

I echo much of what DS4 said. Lifetime max is going to be "per insured person" on the plan. I also would need to know what state and ins. co? Your location says Alabama. Is the quote for someone in Alabama? If so, I am very curious as to the company, because we work with the best non-ACA plan companies and I don't know one that has a benefit design like this? More info would be helpful, if you care to share?

Doubt there's much to share... Original post is nine years old.

 

[JeremySoper]

Nope