Hello,
I am helping a friend, who is on short-term disability pick a plan. She does have regular medical needs and is currently on a PPO where she is able to see specialty doctors. She also has to occasionally do Immediate Care. So, she is someone who does need regular health care.
She was looking at two plans for the next few months.
Plan A (PPO): $770 per month
Plan B (OAP): $330 per month
In looking at these, I'm not sure what the advantage of Plan A (I.e. the cost assumes some advantage). I can use some help with any real life examples to help explain why choosing one vs. the other.
I have listed out the below details to compare each plan:
Some questions
- When on short-term, can you choose a health care plan monthly? The website implies there is a yearly cost, but she is only planning on using short-term for the next ~3 months or so.
- Today, when she has a $900.00 annual plan deductible and has used $~450 through now. My understanding is that she is paying a copay ($20.00), but the rest of the bill is paid for by insurance. As an example, a regular doctor visit bill was $249.00, but she paid only $20.00 (which goes against the $900 deductible).
- If she visited a doctor with Plan A and the plan has a 80% in-network coverage, using the previous example, would a $249.00 total bill be $49.80 for her to pay (249 * .20%)?
- What are we missing with Plan B? It also allows her to keep seeing her current doctors so is flexible like a PPO, but, using the above examples, she would only have a $20.00 copayment for a doctor visit.
It seems to me that Plan A is $400 more expensive and you pay more for each doctor visit, but could use some help in correcting me if I'm not reading this right
I am helping a friend, who is on short-term disability pick a plan. She does have regular medical needs and is currently on a PPO where she is able to see specialty doctors. She also has to occasionally do Immediate Care. So, she is someone who does need regular health care.
She was looking at two plans for the next few months.
Plan A (PPO): $770 per month
Plan B (OAP): $330 per month
In looking at these, I'm not sure what the advantage of Plan A (I.e. the cost assumes some advantage). I can use some help with any real life examples to help explain why choosing one vs. the other.
I have listed out the below details to compare each plan:
Some questions
- When on short-term, can you choose a health care plan monthly? The website implies there is a yearly cost, but she is only planning on using short-term for the next ~3 months or so.
- Today, when she has a $900.00 annual plan deductible and has used $~450 through now. My understanding is that she is paying a copay ($20.00), but the rest of the bill is paid for by insurance. As an example, a regular doctor visit bill was $249.00, but she paid only $20.00 (which goes against the $900 deductible).
- If she visited a doctor with Plan A and the plan has a 80% in-network coverage, using the previous example, would a $249.00 total bill be $49.80 for her to pay (249 * .20%)?
- What are we missing with Plan B? It also allows her to keep seeing her current doctors so is flexible like a PPO, but, using the above examples, she would only have a $20.00 copayment for a doctor visit.
It seems to me that Plan A is $400 more expensive and you pay more for each doctor visit, but could use some help in correcting me if I'm not reading this right
| Benefit | Plan A (PPO) | Plan B (OAP) |
| Plan Year Max Benefit | Unlimited | Unlimited |
| Lifetime Maximum Benefit | Unlimited | Unlimited |
| Annual out-of-pocket max | Individual: $1,200 in-network, $4,400 out-of network | Individual: $6,600 |
| Annual plan deductible | $500 per enrollee | $0 |
| Out-of-Network hospital admission | 60% covered; deductible applies after $400 per admission | Contact plan adminstator |
| Impatient/hospital admission | 80% covered; deductible applies after $200 per admission | 100% after $250 copayment |
| Outpatient surgery | 80% covered; 60% allowable charges out-of-network | 100% after $150 copayment |
| Diagnostic lab & x-ray | 80% in-network; 60% allowable charges out-of-network | 100% |
| Emergency room hospital services | $400 additional deductible | $200 copayment per visit |
| Physician & Specialist office visits | 80% in-network; 60% allowable charges out-of-network | 100% after $20 copayment |
| Preventive services, including immunizations | 100% in-network; 60% allowable charges out-of-network | 100% |
| Telemedicine benefit | $10 copayment, deductible applies, in-network only | $10 copayment |
| Durable medical equipment | 80% in-network; 60% allowable charges out-of-network | 80% network charges |
| Home health care | 80% in-network; 60% allowable charges out-of-network | $15 copyment |
| Prescription Drugs copayment | Tier 1: Greater of 20% of $7 | Tier 1: $10 |
