Dumb question about PPO insurance and delivery

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SoCaliLover's picture
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Dumb question about PPO insurance and delivery

Okay, I know some of you have dealt with this so help me out. Tiff is covered under our insurance and will be for the birth of the baby. Actually, to be more accurate, Tiff is covered under DH's insurance which is a PPO while I have always been under a HMO. Since we have rarely had any issues, I really don't understand how a PPO works.

I need to be able to tell Tiff what the birth of this baby will cost. It looks like first she has to pay 100% of the deductible --which is $500 --according to the online claims, she has met this when she was sent to the hospital a few weeks ago for monitoring. (Boy she will be shocked when she gets that bill!)

What then? According to the benefits, it says the plan covers "90% of eligible expenses after satisfying $500 deductible." So insurance will cover 90% of the bill? But what if something goes nuts? With Zayden, our combined bills (mine as well as his NICU at the children's hospital) was 160k -- so that would give her a bill of $16,000? That can't be right.

What am I missing?

SID081108's picture
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Amy, every PPO plan has an out of pocket maximum. So first is the deductible (looks like she's done with that), then coinsurance (hers is 10%), up to the out-of-pocket maximum. Mine is $2,000 per year (on a PPO) and that includes the deductible. Some OOP maximums do not include the deductible. So what you need to find out is what the maximum is, and then you can better estimate her out of pocket cost. For me, I could pretty much guarantee that I was going to get to the $2,000 (and I did). And that did not include Layla's costs....she had her own deductible, her own coinsurance, and her own out-of-pocket max. My deductible is lower ($300) but my coinsurance is higher (20%). I ended up owing somewhere around $3,000 total including my costs and Layla's, but that also included my weekend hospital stay when Layla was about a week old.

Does that help?

Lavender444's picture
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She would be best off calling her insurance company and having them explain her paticular plan to her. Each insurance company is a little different, and PPO plans within the same insurance company can be different, depending on the employer.

I have a PPO plan as well. We paid 80/20 up to an annual deductible. After the deductible is reached the PPO pays for everything at 100%. Each calenday year, the deductible starts over. So any bill she may have aquired prior to the New Year no longer count for this years deductible.

SID081108's picture
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In a PPO, deductible always comes before coinsurance (80/20, 90/10) unless you have an HSA or HRA arrangement. Yes, plans are all different, but terms like "deductible" and "coinsurance" must be used in the same way by all companies, otherwise it would cause confusion by consumers.

P.S. this is what I do for a living Wink Amy, if you want to send me DH's Summary of Benefits (or sometimes called Schedule of Benefits) I can give you more information about his benefits. Or, as Amber said, you can call and they will outline it for you.

SoCaliLover's picture
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Thanks!! Carrie --PM me your email -- I may have another question or two --these things look greek to me.

I did look at it agin and found the out of pocket max at 2k -- I am not sure if that includes the deductible or not? Almost looks like it does not -- so she will need to pay the 500 and then what ever is left until the 2000 is met? that seems pricy!

I would love Tiff to call and find out but that is probably not going to happen LOL she is covered under DH's plan (which we are now having to cobra). I'd call but last time I did --since I am not covered --they didn't want to talk to me.

I am not sure if that is going to include Bayleigh or not -- I think --if I am reading this right -- that 2k does include her? or at least costs incident to the birth.

Gesh this is confusing -- I think I'll take my HMO!