Total OOP for the client could be $7000 or more with copays.
$5000 OOP exluding the deductible just means that the deductible is separate from the $5000. Factor in copays and the cost could go up even more.
Basically client is responsible for the 1st $2000 (deductible) then the coinsurance kicks in at whatever rate (20%, 30%, 40%...) until the
$5000 is met. Copays are excluded which means they never go away.
Total OOP for the client could be $7000 or more with copays.
$5000 OOP exluding the deductible just means that the deductible is separate from the $5000. Factor in copays and the cost could go up even more.
Basically client is responsible for the 1st $2000 (deductible) then the coinsurance kicks in at whatever rate (20%, 30%, 40%...) until the
$5000 is met. Copays are excluded which means they never go away.
DUDE....a deductible comes first......out of the clients pocket ....then coinsurance kicks in....80/20,75/25, to a stop loss amount for the client...could be $2,000,$3,000 depending on the contract....could be 100%....so read your specimen policy on what you are selling....and if your selling UA....never mind....
Ok, maybe I'm missing something simple here but I'm having a hard time with OOP and the deductible.
Specifically, I'm looking at a Kaiser plan with $5k/yr OOP that excludes copays and the deductible of $2k/yr.
So, client goes to hospital and....?
Coinsurance kicks in up to the deductible, right?
So wtf, how do I explain OOP?
I don't mean to be mean but how long have you been selling major medical? You need to go back to bootcamp. Satisfy Deductible 1st then co-insurance. Some preventative stuff can be co-insurance only depending on the policy. I'm sorry but you're scaring me.
Some plans, Aetna comes to mind, include the deductible in their OOP wording. Most set the OOP limit in addition to the deductible.
Separate deductibles, such as for Rx, ER, etc are not included in the OOP limit, nor are copays.
So as pointed out above, your OOP is not finite. Throw in some non-par charges by hidden providers (such as anesthesia, lab, radiology, ambulance) and the OOP can really jump.
It is pretty scary agents are selling health and don't even know the basics....
Where's your team spirit man? Act like a douche bag and jump down my throat for having a lapse of memory after too much bookkeeping. Get with it!
Fostover: no, I haven't sold much major med. Kinda slept through that part of the training. I went into this with a focus on life and annuities. But a BIG SHOUT OUT to all the guys on this board who have inspired me to use health as an opener.
For all you kids out there thinking of jumping into this biz a an independent, you have the good fortune to observe the perils of bootstrapping -- public ridicule and SHAME for daring to ask such an elementary question!
Really guys, thanks for the ball tickler! (I kid.... it was a v-8 moment as soon as I read mojo's response.)
Fostover: no, I haven't sold much major med. Kinda slept through that part of the training. I went into this with a focus on life and annuities. But a BIG SHOUT OUT to all the guys on this board who have inspired me to use health as an opener.
It might be offensive when someone writes "It is pretty scary agents are selling health and don't even know the basics...." but it's the truth. You're potentially playing with someones financial security. It's unethical to be an amateur.
Questioning deductible vs OOP and still admitting that you have sold health insurance is scary. How can you advise your clients about an insurance plan when you don't know the basics?
You might want to start a post saying, "I don't currently sell health insurance so I need some elementary questions answered." No one will fault you for lack of knowledge. However, selling a product when you have no idea how they work is borderline criminal!
Maybe you could find a "friend" who does sell health in your area and buy that person lunch in exchange for some training. Additionally, every company your are contracted with has broker reps that are out in the field. I'm sure they will be happy to share their limited information with you.
Good luck and PLEASE, stop selling until you understand the product.
Rick
------------------------------------ ILIAA
Training, Community, Support, and Success Independent Life Insurance Agents Assn rick@iliaa.org
Well in his defense these insurance companies do not make this easy. There is no universal answer.
Company A - OOP is in ADDITION to deductible
Company B - OOP is iNCLUDED in the deductible
Company C - OOP is capped at 20% of the amount displayed (ever look at GR in Norvax shows a $10,000 max OOP)
And HMO's is another issues since while your max might be hit - you may still have co-pays, sometimes per incident, per admission, or per day.
So we can all sit here and proclaim to be insurance experts but half of the Aetna IFP agents I know are not aware that the max OOP includes the deductible, etc., etc.,
Since these insurance companies provide virtually no training and say "here you go, start selling..." - They hold training seminars but usually everyone at the seminar is clueless - I could read the Brochure and Policy in 15 minutes and host the seminar.
Well in his defense these insurance companies do not make this easy. There is no universal answer.
Company A - OOP is in ADDITION to deductible
Company B - OOP is iNCLUDED in the deductible
Company C - OOP is capped at 20% of the amount displayed (ever look at GR in Norvax shows a $10,000 max OOP)
And HMO's is another issues since while your max might be hit - you may still have co-pays, sometimes per incident, per admission, or per day.
So we can all sit here and proclaim to be insurance experts but half of the Aetna IFP agents I know are not aware that the max OOP includes the deductible, etc., etc.,
Since these insurance companies provide virtually no training and say "here you go, start selling..." - They hold training seminars but usually everyone at the seminar is clueless - I could read the Brochure and Policy in 15 minutes and host the seminar.
Agreed. All the fancy terms were learned by studying for our license test are not utilized.
------------------------------------
[COLOR=#000066]"Tell me and I will forget. Show me and I will remember. Involve me and I will understand." Confucius
trained RIGHT by one of the best health agents in the nation
Anyone we know?
Company A - OOP is in ADDITION to deductible
Company B - OOP is iNCLUDED in the deductible
Company C - OOP is capped at 20% of the amount displayed (ever look at GR in Norvax shows a $10,000 max OOP)
Bottom line is, you need to read.
I am familiar with carriers I use on a regular basis, but sometimes need a refresher. I maintain good relationships with my carriers and have reps who are knowledgeable and willing to enlighten me.
Consumers fall into one of two categories. Either they broad brush their search and end up with Mega or they over-analyze.
Of course agents can be just as dumb.
When they over-analyze (consumers & agents) they make it much more difficult than is necessary. Health insurance doesn't have to be complicated but too many make it that way.
Stick with simple plans with no moving parts and everyone will be happier. I use my "pitch" to educate consumers on the complexity of copay plans and move them toward plans with no deductibles.
You're potentially playing with someones financial security.....selling a product when you have no idea how they work is borderline criminal!
Omigawd, Veronica! I didn't know you were such a drama queen!
Really, I might ruin someone's financial security by selling them health insurance? What does that say abouit the carrier that packages the product? (No, I won't sell NAA.)
Was your name Heather in highschool?
Ok, big apology. The student shouldn't mock to teacher. If you (or anyone else) wants to be cock-of-the-walk, go right ahead -- but I will respond with derision. (I know, it's a personal character flaw that has haunted me my entire life.)
I will now be humble.
I'm sure you know your stuff, and I really do appreciate any enlightenment those of you in the know care to share. I am here to learn from people like Rick who have forgotten more than I have learned about insurance.
Seriously, nothing said in this thread offends me, and I hope my weak attempts at humor make you laugh.
Out of Pocket vs. Deductible
Linear Mode
