Wellpoint deductibles and out-of-pocket maximums explained

Let’s help you understand your insurance benefits. If you have them, deductibles and out-of-pocket maximums (MOOP) are two important terms to know. They tell you how much money you might need to pay for medical services with your Wellpoint plan. Learning the difference between these two insurance terms can help you make better choices about your health insurance.

What is a deductible?

 

A deductible is the money you pay out of your own pocket for doctor visits or hospital stays before Wellpoint starts to help cover the costs of care. Once you've paid enough to reach your deductible, Wellpoint will share some of the covered costs.

 

Sometimes when you get insurance, you can pick between plans that offer higher or lower deductibles.

  • A low deductible means you’ll pay less out of pocket if you have unexpected medical costs. But your monthly payment (premium) will be more.
  • A higher deductible means your monthly payments will be less. But you’ll have to pay more out of pocket if you need medical care.

A low deductible plan might be good if you or a family member sees the doctor often or needs prescription medications. You'll pay more each month, but you'll reach your deductible faster. This means Wellpoint will start helping with those costs sooner.

 

A high deductible plan may be a good choice if your family is generally healthy and doesn’t see a doctor outside of regular checkups. You might be okay with paying more out of pocket. Even if unexpected health events happen, you will pay smaller monthly payments.

What type of costs go towards a deductible?

 

Out-of-pocket expenses are the money you pay on your own to your doctor for health services before your Wellpoint plan starts helping pay for costs. What counts towards your Wellpoint deductible can be different depending on your plan. Usually they include:

 

  • Visits to the hospital or emergency room
  • Seeing your doctor
  • Lab tests
  • Prescription medications

 

Many services like these count towards your deductible. However, many Wellpoint plans start covering some services right away. These are preventive care services, like regular checkups with your doctor. Most Wellpoint members don't have to pay anything for these checkups.

 

It’s also good to know that some health plans, like HMOs or different types of Medicaid programs, don’t have a deductible. If you have one of these plans, Wellpoint will start helping with costs right away.

How an out-of-pocket maximum (MOOP) works

 

Every year, there's a maximum amount of money you can pay for your health services. We call this your out-of-pocket, or MOOP, in your Wellpoint plan. This includes your deductible, copays, and coinsurance.

 

Copays are small amounts you pay each time you get care. It’s usually the same amount every time. Coinsurance is a portion of the care costs you’re responsible for. The amount depends on your plan and the cost of the care you received. It is usually not the same every time, but a percentage instead.

 

The money you pay each month for your plan, known as your premium, doesn't count in your MOOP. When you reach this MOOP, Wellpoint will then pay everything else for that year for the services included in your plan. This is how Wellpoint helps protect you from high medical costs and gives you peace of mind.

 

Let’s say you need a surgery that costs $10,000 and your plan has:

  • A $1,500 deductible,
  • A 20% cost of care after you meet your deductible (this is called coinsurance), and
  • A $3,000 MOOP

You’d pay your $1,500 towards the cost of the procedure ($10,000). This leaves $8,500. You’re responsible for $1,700 (20% coinsurance for medical costs once you meet your deductible).

 

Your deductible and your coinsurance for the surgery add up to $3,200, but since your Wellpoint out-of-pocket maximum is $3,000, that’s all you’d pay. Wellpoint would cover the rest of the cost, which is $7,000.

Deductible vs. out-of-pocket maximum

 

Deductibles and out-of-pocket maximums might seem similar, but they are different.  Once you pay enough to reach your deductible, Wellpoint begins to help pay for the health services covered by your plan. Even so, depending on your plan, you might still have a coinsurance payment. But, if you pay enough to get to your MOOP in a single year, Wellpoint then pays all the costs. You don’t have to worry about coinsurance.

 

You might not get to your MOOP every year. It depends on how your plan shares costs and your specific health needs that year. 

When does the Wellpoint out-of-pocket maximum and deductible reset?

 

Your deductible and MOOP start over every year. If you signed up during the typical plan registration time, known as the Open Enrollment Period (OEP), it usually starts on the first day of the year, January 1. However, if you joined through a Special Enrollment Period (SEP), the day these amounts get reset might be different and would depend on when you joined.

Learn more about your Wellpoint deductible and out-of-pocket maximum

 

By knowing how much you might have to pay for doctor's visits with your Wellpoint plan, you can make good decisions about your health. This also helps you make sure you're using your benefits fully. To get the best information about your Wellpoint plan's deductible and MOOP, log into your Wellpoint member portal or download the Sydney℠ Health app on your smartphone.