Out of Pocket Calculator Help

HMO Tiered Benefit

HMO Tiered Benefit is one of the models to select from in the Select a Plan Model portion of the Plan Information section in the General Plan Information Sheet. “HMO” refers to a “Health Maintenance Organization” type of health plan. “Tiered Benefit” refers to there being two different levels of HMO inpatient hospital benefits for participating hospitals- a higher level of benefits for participating hospitals belonging to the Plan’s upper tier list of hospitals, and a reduced level of benefits for participating hospitals belonging to the Plan’s lower tier list of hospitals. Thus while only participating hospitals would have coverage for non-emergency services, the level of coverage for these participating hospitals will differ based upon which tier the plan has classified the hospital in.

Using the Tiered Benefit model is more complex because of this nuance. Default values for the lower tier participating hospitals have been placed in the “non participating hospital” portions Copay/Coinsurance and Deductible/Maximums Sheets for the Tiered Benefit Model. Thus if you want to calculate an Out of Pocket Estimate Report for a lower tier hospital, you would select “No” in the participating hospital question in the Coverage Information section of the General Plan Information Sheet, use or modify the default non participating hospital values provided in the other Sheets and then Run the Report. On the other hand, if you wanted to Run a Report for a truly non-participating hospital under this model, you would need to change the non participating hospital default values in the sheets to indicate no coverage applies.

The HMO Tiered Benefit model assumes the following default benefit features:

General Individual Deductible: $0
General Family Deductible: $0
Inpatient Deductible Per Admission- Participating Hospitals: $250
Inpatient Deductible Per Admission- Non-Participating Hospitals: $250 (actually applies to lower tier participating hospitals)
Coinsurance- Participating Hospitals: None
Coinsurance- Non-Participating Hospitals: 15% (actually applies to lower tier participating hospitals)
Maximum Allowable Per Day- Non Participating Hospitals: NA
Maximum Individual Annual Out of Pocket – Participating Providers: $2,500
Maximum Individual Annual Out of Pocket – Non Participating: $3,000 (actually applies to lower tier participating hospitals)
Maximum Family Annual Out of Pocket – Participating Providers: $3,000
Maximum Family Annual Out of Pocket – Non Participating: $6,000 (actually applies to lower tier participating hospitals)