YES PLEASE, MORE INFORMATION
To understand how plans work, you can break it down into three phases….
PLAN 1
Phase 1
You’re responsible to pay the first dollar costs for medical services and prescriptions (Rx) until you meet your deductible.
Phase 2
So you’ve met the deductible. Now coinsurance kicks in for all medical services and copays apply to Rx. That’s right, you’ll pay 20% of the cost for medical services and the plan pays the rest! You’ll pay the copay for Rx and the plan pays the rest!
Phase 3
You’ve got a maximum out-of-pocket. This amount is an accumulation of the deductible, coinsurance, and copays. Once all these costs add up to the max out-of-pocket the plan will pay 100% of all in-network, covered medical services and Rx for the rest of the policy year. Yep, you read that right.
PLAN 2 & PLAN 3
You pay the copay amount for day to day services, as stated on page 3. Your deductible applies to these additional services. Once you meet your deductible your coinsurance will “kick in”, you pay 20% of the cost and AMIkids pays 80% of the cost of the claim. The amounts you pay towards your deductible, in coinsurance, copay amounts, and prescription copays apply to your out-of-pocket maximum.
GOT THAT. WHAT NOW?
EMBEDDED V.S. NON-EMBEDDED?
An Embedded plan means that for family coverage, each family member is only responsible for the individual deductible and individual max out-of-pocket. BUT the family as a whole will never exceed the family deductible and family max out-of-pocket.
Yes, this means that if one member reaches the deductible, they will go into coinsurance. If they meet their max out-of- pocket they will be covered 100%, even if no one else in the family has met the deducible.
All three of the AMIkids Medical Plans for 2017 have Embedded deductibles, but just in case you’re interested in what happens in a Non-Embedded plan. . .
On a Non-Embedded plan, if you have one of more covered dependents, either a single family member OR an accumulation of the family is responsible for the family deductible before you have coinsurance. Ultimately, if you have non-embedded plan AND dependent (spouse and/OR child(ren)) coverage, the individual amounts will not apply to you.
Yes, this means that one family member may be responsible for the entire family deductible. Once the family deductible is met all covered members will be covered under coinsurance.
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