Insurance - out of pocket cost question...?

Question

I am trying to do an IVF in January-
our insurance states that the Deductable is 2,200 and they pay 90% - after satisfying the out of pocket cost at 3,000 it is covered at 100%

it goes on to explain "out of pocket maximum - includes expenses applied to the deductable PLUS your co-insurance maximum"...

to me this sounds like the total out of pocket cost I can pay is 2,200 for the deductable and an addition 800 would satisify the out of pocket cost and they should start paying at 100%...
but when i asked my benefits dept they said it how it works is i would pay 2,200 for the deductable and an addition 3,000 would satisify my out of pocket cost ...

does this sound right?

Answer 1

The HR department is right. The out of pocket maximum is referring to the co-insurance. Your total will be $5200 before you're covered at 100%

Make sure to get any pre-approvals from the insurance company before you do the procedure. Many plans do not cover IVF or they may have limited coverage.

Answer 2

You'd have to pay the deductible PLUS the out of pocket maximum. (Out of pocket maximum refers only to the coinsurance...that 10% that you pay AFTER you've already paid the deductible.)

Also...generally if you have an office visit copay, you'll still be liable for that even if you do meet your deductible and out of pocket maximum. So technically you could pay out *more* than $5200 for the year.

Also...keep in mind that those are likely your "in-network" benefits. With something like IVF, its possible you could end up encountering some out of network providers. In which case your out of network benefits, whatever they may be, could come into play.

Finally, before you start planning around these numbers, make sure that IVF is actually covered by your policy. Its a rarity for an employer policy to cover IVF, though it does happen occasionally.

Also, even for those rare policies that *do* cover IVF, sometimes there are limitations...for example, they'll pay X dollar amount towards IVF, and then you're liable for everything above and beyond that. (Regardless of whether your deductible and out of pocket maximum are met.)

Answer 3

You are advised to contact the benefits department of the insurer directly for information. HR departments are not experts at coverages.

Insure that your insurer actually covers IVF under the policy, since it's relatively rare for an insurer to do so.

Answer 4

No that doesn't sound right. Maximum out of pocket is the "maximum" you have to pay. To be sure call the insurance company for clarification. Also make sure they cover all of the IVF services. Anything not covered does not apply to your maximum out of pocket.

I have been mislead by HR before on benefits. Rely on what the insurance company says.