An “out-of-pocket maximum” is a common health insurance term that you may not fully understand. Your out-of-pocket maximum can provide financial protection in years when you need a lot of treatment by capping the total amount you spend on medical expenses. Understanding your out-of-pocket maximum can significantly impact your financial planning and ability to manage medical expenses. This article provides an overview of out-of-pocket maximums.            

Overview of Out-of-Pocket Maximums

Your out-of-pocket maximum is the maximum amount of money you must pay for covered health care services during a specific period, typically a year. Once you’ve reached your out-of-pocket maximum, the insurance plan will typically cover 100% of your covered, in-network health care costs for the rest of the year. At the end of your policy year, your out-of-pocket maximum will typically reset.

Understanding how your out-of-pocket maximum works in practice can help you be aware of how it will impact your finances. For example, imagine that your health insurance plan has an out-of-pocket maximum of $6,000 per year, a $1,000 deductible and a 20% coinsurance. In this scenario, you will pay your $1,000 deductible upfront when you use your plan and an additional 20% of all covered medical expenses afterward. Your insurance company will pay the remaining 80% of covered medical expenses as you continue to incur medical costs for the year. Your medical spending will accumulate until you reach your out-of-pocket maximum of $6,000. Once you reach this limit, your insurance company will typically pay for 100% of your covered health care costs for the rest of the year.

Expenses That Count Toward Your Out-of-Pocket Maximum

The exact details regarding expenses that count toward your out-of-pocket maximum may vary with your health care plan, so it’s important to read the fine print. Your out-of-pocket maximum will typically include various expenses incurred during the policy year, such as deductibles, copayments and coinsurance. However, some plans don’t count all of your copayments, deductibles, coinsurance or other expenses toward this limit. Additionally, your monthly premiums and out-of-network expenses won’t usually count toward your out-of-pocket maximum.  

Selecting an Out-of-Pocket Maximum

You can typically choose from various health care plans with different out-of-pocket limits. You should keep in mind that plans with lower out-of-pocket maximums usually have higher premiums. Conversely, health care plans with higher out-of-pocket maximums generally have lower premiums. However, some employers only offer one option. If this is the case, it’s important that you note what your out-of-pocket maximum is. You may be eligible for lower out-of-pocket maximums if you earn under certain income thresholds or meet other requirements.

Conclusion

Your out-of-pocket maximum is essential for managing health care costs and providing peace of mind in times of medical need. It allows you to anticipate and allocate funds for your health care expenses and can help you avoid catastrophic health care bills that could otherwise lead to financial hardship.

Selecting and utilizing dental benefits is crucial because the condition of your teeth and gums significantly impacts your overall health. Proper oral health care can help prevent oral infections, tooth decay, gum disease, and other conditions. Not only does good oral health support your teeth and gums, but your overall health and well-being.  

Here are some of the ways dental hygiene can affect your overall health:

• Help cardiovascular health. Gum disease increases inflammation in the body, including within the soft tissues of the heart. Plaque and bacteria enter the body through the gums and can clog arteries and increase your risk of a severe heart attack or stroke.
• Decrease the risk of experiencing dementia. Poor dental hygiene can cause you to suffer from tooth decay and even tooth loss. Substances entering your body through your gums can negatively impact your brain’s functions. In turn, there is a higher potential for memory loss which can develop into dementia.
• Improve respiratory conditions. Bacteria can travel from your mouth to the bloodstream and into your lungs, directly impacting your respiratory system. Good oral hygiene can help prevent unwanted bacteria from traveling further into your body.
• Lower the risk of diabetes. People with gum disease are more prone to developing diabetes. The reverse is also true; those with diabetes are more prone to gum disease. If you already have diabetes, it’s vital to maintain good oral hygiene for prevention, as you’re more likely to contract certain infections when you have diabetes.
• Prevent some infertility risks. Gum disease can cause infertility issues such as premature birth and low birth weight. Maintaining good oral hygiene can help increase your odds of a normal pregnancy.

How to Practice Good Oral Hygiene

It’s important to practice oral hygiene for your overall health and well-being. Here are a few tips to help prevent periodontal diseases and health issues:

• Brush your teeth daily. Brushing your teeth at least twice daily can help clean your teeth and gums of bacteria and food debris within your mouth.
• Schedule regular dental appointments. Have your teeth cleaned at least once a year in order to maintain good oral hygiene.
• Change your toothbrush every couple of months. You use your toothbrush every day. Changing your toothbrush every couple of months helps minimize the amount of bacteria on the toothbrush, preventing it from being transferred to your mouth.
• Eat firm, whole foods. Firm foods can also help clean your teeth as you eat. Consider foods such as carrots, apples and celery in your diet.

Learn More About Oral Hygiene

Good oral hygiene needs to be a top priority to maintain good overall health status. A healthy mouth is often a sign of a healthy body.

Do you need to learn more about dental benefits or dental insurance? Contact us today. 

If your employer offers health benefits, there is a chance they offer a Health Savings Account compatible plan. You may be familiar with those type of plans, or it may sound like a different language. Don’t fret if you don’t understand. That’s where we come in. Below is a basic breakdown of an HSA.

What is a Health Savings Account?

Also known as a HSA, a Health Savings Account is a savings account that you can use to pay for medial related expenses. It can be funded by tax-exempt dollars by your employer, by yourself or by anyone else on your behalf. The funds in the HSA account can help pay for eligible medical expenses not covered by an insurance plan. This can include copays, deductible, coinsurance and prescriptions.

Who is eligible for a Health Savings Account?

In order to open and contribute to a HSA plan there are a few stipulations. You are eligible if you are:

•  Covered by a high deductible health plan (HDHP)
•  Not covered under another medical plan that is not an HDHP
•  Not entitled to (eligible for AND enrolled in) Medicare benefits
•  Not eligible to be claimed on another person’s tax return

What is a HDHP?

A high deductible health plan is a plan with a minimum annual deductible and a maximum out-of-pocket limit that is set by the IRS. These limits change annually but for 2021 the limits are as follows:

Type of Coverage                    Minimum Annual Deductible                    Maximum Annual Out-of-pocket
Individual                                    $1,500 for 2023                                             $7,500 for 2023
Family                                         $3,000 for 2023                                            $15,000 for 2023

So how does it work?

Your high deductible health plan does not provide co-pays when you visit a Dr or pharmacy. That leaves you to pay the total expense of the visit or the prescription. Your claims will still be ran through your insurance company and most will be re-priced at the negotiated price from your insurance company. You can then use the funds in your HSA account to pay for those expenses. Most HSA accounts will offer checks or debit cards to make paying bills easy. The important thing is to make sure you are using those funds for qualified medical expenses. If you use the money for non medical expenses you will be subject to additional taxes and penalties.
Click here to learn how your HSA works with Retirement.

HSA Contributions

You can make a contribution to your HSA each year that you are eligible. You can contribute no more than:

•  Single coverage: $3,850 for 2023
•  Family coverage: $7,750 for 2023
Individuals ages 55 and older can also make additional “catch-up” contributions of up to $1,000 annually.

A few more things.

Unlike other accounts, a HSA is not one that you have to use or loose by the end of the year. You can contribute money into this account and not touch it for years. It will just stay in the account until you need it. The IRS also puts yearly caps on how much you can contribute each year into your HSA. You can click here to learn more.

If you have additional questions, we are are happy to help! 

Health insurance may be one of the most critical annual purchases since it impacts your physical, mental and financial wellness. Unfortunately, selecting a health insurance plan can feel overwhelming. With so many options, it can also be easy to make a mistake when selecting coverage.

This article explores six common missteps related to selecting a health insurance plan. Once armed with this information, it’ll be easier to avoid these mistakes and choose the best plan coverage for your situation.

1) Rushing Through Enrollment Options

Many people rush when buying their health insurance or only rely on recommendations from friends, family and co-workers. Others may simply reenroll with last year’s choices. But health insurance provides personal coverage, so it’s important to research and find what will work best for your health needs and budget.

When it comes time to enroll in a plan, compare different policies and understand their coverages and associated costs (e.g., premiums). One of the best ways to ensure the policy is right for your health needs is to consider your medical requirements and spending in the next year. Don’t forget to confirm in-network coverage to ensure your preferred doctor, clinic and pharmacy are connected in the new plan. Then, you can find the most suitable plan and coverage in an effort to simplify your health care and make it more affordable.

2) Overlooking Policy Documents

Another common mistake is skipping through or not thoroughly reading the policy’s terms and conditions. However, carefully reading a policy is the best way to know what to expect from the health plan and what the plan expects of you.

As such, read the fine print on each plan you consider before enrollment. Reviewing the policy’s inclusions and exclusions will help you make an informed decision and potentially avoid surprise bills later on.

3) Misunderstanding Costs

A cost-sharing charge is an amount you must pay for a medical item or service covered by the health insurance plan. Plans typically have a deductible, copays and coinsurance. Here’s what those terms mean:

• The deductible is the amount you pay out of pocket before your health insurance starts to cover costs.
• A copay is a flat fee you pay upfront for doctor visits, prescriptions and other health care services.
• Coinsurance is the percentage you pay for covered health services after you’ve met your deductible.

When shopping for a plan, keep in mind that the deductible is tied to the premium. As such, a low deductible plan may seem attractive, but understand that it generally comes with a higher premium—and vice versa. Consider keeping your deductible to no more than 5% of your gross annual income. When shopping for a plan, look closely to see when you’ll have a copay and how much it will cost for various services.

4) Concealing Your Medical History

It may be tempting to avoid sharing your medical history if you’re worried about being rejected or receiving higher premiums. However, it could hurt you in the long run when insurance claims are denied for existing conditions or undisclosed medical information.

5) Ignoring Add-ons

Health insurance add-ons are often included separately and require an additional premium, which means many people don’t look at them. A standard health insurance plan may not cover certain situations, so reviewing all available options is essential. An insurance add-on could help bolster your overall health insurance coverage by offering extra protection.

Review the add-on covers offered with your health insurance policy and see if any would be helpful for you, your family or plans in the next year. For example, some common add-ons include critical illness insurance, maternity and newborn baby insurance, hospital daily expenses and emergency ambulance services.

6) Selecting Insufficient Coverage

People may hold back on purchasing certain coverage to pay a lower premium. While that may seem advantageous in the short term, you’ll be on the hook for out-of-pocket costs when facing a medical emergency. This mistake may be accompanied by physical, mental and financial health consequences.

When selecting a plan, check that the policy provides adequate coverage for your medical needs and other essentials. The right health insurance can take care of yourself and ensure financial security.

Summary

Health insurance is an essential investment for you and your family. By avoiding common mistakes while buying health insurance, you’ll be better informed to enroll in a plan and other coverages.

As health care costs continue to rise, it’s more important than ever to carefully review available policies, consider your options and health needs, and, ultimately, select the best plan to protect your health and finances.

When it comes to benefits, such a health insurance, many can agree that it is confusing. Unless you are involved in health insurance or Human Resources it can be hard to make sense of everything. We have compiled a list of some of the 7 most frequently asked benefit questions and their answers. We hope this makes things a little easier to understand. 

What is a Deductible?

A deductible is the amount of money you or your dependents must pay toward a health claim before your organization’s health plan makes any payments for health care services rendered. For example, lets say you have a $1,000 deductible. You would be required to pay the first $1,000, in total, of any claims during a plan year.

What is Coinsurance?

On top of your deductible, coinsurance is a provision in your health plan that shows what percentage of a medical bill you pay and the percentage a health plan pays. This usually starts after your deductible has been satisfied.

What is an Out-of-pocket Maximum (OOPM)?

An OOPM is the maximum amount (deductible and coinsurance) that you will have to pay for covered expenses under a plan. Once the OOPM is reached the plan will cover eligible expenses at 100 percent.

What is an Explanation of Benefits (EOB)?

An EOB is a description your insurance carrier sends to you. It explains the health care benefits that you received and the services for which your health care provider has requested payment. It will explain what your insurance carrier will pay and an cost your will be responsible for. This would include Deductible, Coinsurance, Copays, etc.

What is a Preferred Provider Organization (PPO)?

A PPO is a group of hospitals and physicians that contract on a fee-for-service basis with insurance companies to provide comprehensive medical service. If you have a PPO, your out-of-pocket costs may be lower than in a non-PPO plan.

What is Utilization Management (UM)?

Utilization Management is the process of reviewing the appropriateness and the quality of care provided to patients. UM may occur before (pre-certification), during (concurrent) or after (retrospective) medical services are rendered. 

For example, your health plan may require you to seek prior authorization from your UM company before admitting you to a hospital for nonemergency care. This would be an example of pre-certification. Your medical care provider and a medical professional at the UM company will discuss what is the best course of treatment for you before care is delivered. UM can reduce unnecessary hospitalizations, treatment and costs.

What is a High Deductible Health Plan (HDHP)?

An HDHP is a type of insurance plan that offers a low premium offset by a high deductible. Because of the low cost of the plan, the insurer will not cover most medical expenses until the deductible is met. As an exception, preventive care services are typically covered before the deductible is met. HDHPs are often designed to be compatible with heath savings accounts (HSAs). HSAs are tax-advantaged accounts that can be used to pay for qualified out-of-pocket medical expenses before the HDHP’s deductible is met.

We hope you found this list of 7 most frequently asked benefit questions and their answers helpful. If you did, please take a moment to share this post. 

Would you like to know more about health insurance? Click here for Individual or Click here for Employee Benefits.