The document provides information about an employee health insurance plan, including details about deductibles, out-of-pocket limits, covered services, and networks. It explains that the plan has a $1,000 individual/$2,000 family deductible for in-network and $2,000/$4,000 for out-of-network. The out-of-pocket maximum is $4,000 individual/$8,000 family for in-network and $10,000/$20,000 for out-of-network.

1. Simple Solutions for Complex Employee Benefits Needs | wellstoneba.com | 913.438.3433

2. Tom O’Connor, President | wellstoneba.com | 913.438.3433
Tom O’Connor
President, Wellstone Benefits Advisors
• Advanced Chartered Benefits Consultant
• National Association of Health Underwriters Self-
Funded Certification
• Providing employee benefit plan design, financial
and insurance consulting since 1986

3. Tom O’Connor, President | wellstoneba.com | 913.438.3433
#1: What Is The Overall Deductible
Network: $1,000 Individual & $2,000 Family
Non-network: $2,000 individual & $4,000 Family
Doesn’t apply to Rx drugs and network
preventative services. Coinsurance and
copayments don’t count towards the deductible
Generally, you must pay all of the costs from
providers up to the deductible amount before this
plan begins to pay. If you have other family
members on the plan, each family member must
meet their own deductible until the total amount of
the deductible expenses paid by all family
members meets the overall family deductible.

4. Tom O’Connor, President | wellstoneba.com | 913.438.3433
#2: Are these services covered before you
meet your deductible?
Network Providers: Yes. Preventive, Certain
Office Visits, Emergency Room Care, Urgent
Care, Prescription Drugs and Certain Therapies.
Non-Network Providers: Yes. Emergency Room
Care and Prescription Drugs
This plan covers some items and services even if
you haven’t yet met your deductible amount. But a
co-payment or co-insurance may apply. For
example, this plan covers certain preventive
services without cost sharing and before you meet
your deductible. See a list of covered preventive
services at:
https://www.healthcare.gov/coverage/preventive-
care-benefits/.

5. Tom O’Connor, President | wellstoneba.com | 913.438.3433
#3: Are there other deductibles for
specific services?
No You don’t have to meet deductibles for specific
services

6. Tom O’Connor, President | wellstoneba.com | 913.438.3433
#4: What is the out-of-pocket limit
for this plan
Network Providers: $4,000 individual $8,000
Family
Non-Network Providers: $10,000
individual/$20,000 Family
The out-of-pocket Limit is the most you could pay
in a year for covered services. If you have other
family members in this plan they have to meet
their own out-of-pocket limits until the overall
family out of pocket limit has been met.

7. Tom O’Connor, President | wellstoneba.com | 913.438.3433
#5: What is not included in the
out-of-pocket limit?
Premiums, Balance-billing charges, health care
this plan doesn’t cover, penalties, non-network
transplant, non-network prescription drugs and
non-network specialty drugs
Even though you pay these expenses, they don’t
count toward the out-of-pocket limit

8. Tom O’Connor, President | wellstoneba.com | 913.438.3433
#6: Will you pay less if you use a
network provider
Yes. See
www.humana.com/directories or call 1-888-
4assist(427-7478 for a list of network providers
For Prescription Drugs: National Rx network
This plan uses a provider network. You will pay
less if you use a provider in the plans network.
You will pay the most if you use an out-of-network
provider, and you might receive a bill from a
provider for the difference between the provider’s
charge and what your plan pays (balance billing)
Be aware, your network provider might use an out-
of-network provider for some services (such as lab
work). Check with your provider before you get
services

9. Tom O’Connor, President | wellstoneba.com | 913.438.3433
#7: Do you need a referral to
see a specialist?
No You can see the specialist without a referral

10. Tom O’Connor, President | wellstoneba.com | 913.438.3433
$1,000 Deductible + 30% co-insurance of next $10,000
Individual Maximum Plan liability Out of Pocket cost - $4,000
Total event cost $7,852
Minus Deductible of $1,000.00 = $6,852
30% co-insurance of $6,852 = $2,055.60
Add deductible of $1,000.00
Total Individual out of pocket Cost = $3,055.60

11. Tom O’Connor, President | wellstoneba.com | 913.438.3433
1. Do I get an annual physical?
Yes, every year. No. Why not?
2. What medications do I take?
Are they generic? Why not?
3. Do I take medications as directed? Am I compliant?
If not, you are putting your health at serious risk
4. Do I exercise regularly
5. Is my BMI within an acceptable range?

12. Tom O’Connor, President | wellstoneba.com | 913.438.3433
Contact me. I’ll show you how.
Tom O’Connor
tom@wellstoneba.com
913.438.3433
Website:
Wellstoneba.com
LinkedIn:
linkedin.com/in/tom-oconnor-kc