Take charge: Out-of-pocket maximums
When you use your Asante Health Plan, you share the cost of care with the plan when you pay your deductible, your copays and your coinsurance. But did you know that there’s a limit to how much you’ll pay over the calendar year? That amount is called an out-of-pocket maximum.
Each Asante Health Plan medical option has a dollar amount listed for the out-of-pocket maximum. When you use medical services, the amount that you pay toward your deductible, copays and coinsurance all go toward that maximum, and once you reach it, your plan pays 100% of allowed charges for the rest of that calendar year. The amount taken from your paycheck for the cost of the plan, however, does not go toward the maximum.
Based on the Asante Health Plan option you choose, you may have an individual out-of-pocket maximum and one for the family. In this case, when the deductible, copays and coinsurance for one person reaches the individual max, the plan would pay 100% of allowed charges for that person. When what is paid reaches the family maximum, the plan would pay 100% of allowed charges for everyone on the plan.
If your plan’s individual out-of-pocket maximum is, say, a hypothetical amount of $1,500, once you have paid out $1,500 for health care services, the plan covers 100% of charges for the rest of the year. If the same plan has a hypothetical family out-of-pocket maximum of $3,000, and two people on the plan had each paid $1,500 for services, the plan would then pay 100% of the charges for them and anybody else on the plan. Maximums may be different, depending on the plan option you choose.
If you or your family face a year with high medical expenses, it can be comforting to know that you won’t necessarily be responsible for the full charges.
You can find more information on the Asante Health Plan options on myHR or Asante.org.
If you have any questions, please email the Asante Benefits department or call (541) 789-4551. You can also submit a case in the Ask HR section of myHR.
More in the Take Charge series
Asante Health Plan provider networks
What is a health plan deductible?
If you need answers for a personal work matter, please contact the author or department directly instead of leaving a comment.
How does our insurance work with Medicare A and/of B ?
I am turning 65 in Sept, not retiring for awhile.
Please share the reality of using non-APP providers. Perhaps a comparator with a Regence provider since we are part of their network.
If an individual is enrolled in the Asante plan as well as Medicare A and/or B, the Asante plan would be considered primary, and the Medicare plan would be considered secondary.
An individual who gains Medicare A and/or B has the opportunity to drop their Asante medical coverage if they do so within 30 calendar days of the Medicare coverage starting, but they are not required to do so.
If the provider is part of category 2, services would pay at that rate. However, if the provider is category 3, which is a specialist that is not part of the Asante Health Network that provides services that are offered by providers in the Asante Health Network, services would pay at the category 3 rates. The amount that is paid can vary based on the health plan option, the service, etc.
You can find additional information at www.asante.org/employee-benefits.
The out of pocket maximum sounds like a great deal on the surface. The real story is that there is an out of pocket maximum for every provider category. You have to reach the max annual payout for every category independent of the other categories. For example $1,500 for Asante Providers PLUS $3,000 for category 2 Regence preferred providers PLUS $5000 for category 3 Non-preferred providers. These amounts do NOT cross cover and must be met independent of the other maximum out of pockets. (The dollar amounts are arbitrary and not actual amounts from our plans.)
Thank you for the response.
The plan is set up so that out-of-pocket maximums do cross accumulate between categories 1, 2 and 3; there’s no cross accumulation for category 4 expenses.
If you have additional questions, please feel free to contact 541-789-4551 or [email protected]