Deductibles & Maximum out of pockets

Deductibles &Maximum out of pockets Part of the Medical Plan 1

Definitions Deductible: An amount you pay (once each year) BEFORE the insurance kicks in For example, if you experience a $20,000 hospital stay and you have a $1500 deductible, you will need to pay the first $1500 of that charge before co-insurance begins to apply

Definitions – cont. Co-insurance: After the deductible is met, you and the insurance company share in the payments For example, if the unpaid balance AFTER your deductible is $18,500, the insurance plan will pay 90% of the balance and you pay 10% (assuming you are in-network). This continues until you hit your maximum out-of-pocket.

Definitions – cont. Maximum out-of-pocket: A dollar limit on the most you have to pay in a calendar year. For example, if your Maximum out-of-pocket is $3000, once you have paid $3000 for deductible and co-insurance, the insurance plan kicks in and pays 100% of covered charges for the balance of that calendar year.

Definitions – cont. Illustrating total charges of $50,000 With no Max out-of-pocketYou pay Insurance pays Deductible $1,500 Co-insurance 4,750 $43,750 Additional expenses 10% 90% With Max out-of-pocket Deductible $1,500 Co-insurance 1,500 $47,000 Additional expenses 0% 100%

Definitions – cont. In-network: Your portion (co-insurance) is 10% if your service is within the CMH PHO 30% if in the United Healthcare Options PPO 50% if outside both of these networks.

Definitions – cont. The CMH PHO consists of • CMMC, Lewiston • Bridgton Hospital • Rumford Hospital • Parkview Hospital, Brunswick • Franklin Memorial , Farmington Access the listing at “Find a doctor” at www.cmmc.org

Definitions – cont. The United Healthcare Options PPO consists of healthcare providers who have contracted with UHC to accept payments as submitted (won’t balance bill the patient). Typically they also offer their patients a negotiated discount. http://www.umr.com/oss/cms/UMR/Options_PPO_Exclusions.html

Definitions – cont. Premiums: The amount paid by CMH and by employees to provide coverage. Overall, CMH pays nearly 75% of the total premiums on Medical Insurance As you review your options and “do the math” for which coverage makes the most sense for you and your dependents, realize you are seeing only a fraction of the total cost for coverage.

Definitions – cont. Pre-tax premiums: The federal government allows premiums to come out before FICA, Medicare, federal and state deductions. Your actual cost is really close to ¾ of what you see as a deduction. So a $200 deduction really “costs” you about $150. For those covering domestic partners, remember the portion of the premium that represents your partner’s coverage must be taken as an after tax deduction.

What are the deductible levels? There are two different deductible levels and each has an in-network and out-of-network amount. The individual deductibles are: CMH PHO UHC Options PPO Outside both (10% co-ins.)(30% co-ins.)(50% co-ins.) Lower deductible $ 500 $1000 $1000 Higher deductible $1500 $3000 $3000

Is there a family deductible? Yes, there is protection for three or more people on the same contract that prevents each person from having to meet the full (individual) deductible. The family deductible information is: Family Ded. Family Ded. Family Ded. CMH PHO UHC Options PPO Outside both (10% co-ins)(30% co-ins)(50% co-ins) Lower deductible $1000 $2000 $2000 Higher deductible $3000 $6000 $6000

What are the Maximum out-of-pocket limits? Individual Maximum out-of-pocket limits are: CMH PHO UHC Options PPO Outside both (10% co-ins.)(30% co-ins.)(50% co-ins.) Lower deductible $2000 $4000 $4000 Higher deductible $3000 $6000 $6000

Is there a family Maximum out-of-pocket limit? Family maximum out-of-pocket limits are: Family MOOP Family MOOP Family MOOP CMH PHO UHC Options PPO Outside both (10% co-ins)(30% co-ins)(50% co-ins) Lower deductible $4,000 $8,000 $8,000 Higher deductible $6,000 $12,000 $12,000

Deductibles & Maximum out of pockets