Max Out of Pocket Question

[Timoyal 0]

Good Morning All!!

I have a question for you. I spoke with my insurance company again yesterday and was told that all I would have to pay is my max out of pocket which is $4500 no matter how much my deductible ($2500) or co-insurance (20%) is. Does anyone know if this is true or had this happen and can share your experience.

Thanks is advance!!

[emjay 8]

Its hard to know without looking at your Summary Plan Description booklet. It all you have to pay is $4500, then it sounds like your deductible amount is included in your max OOP max amount. Ours isn't, but some plans do. Your co-insurance amount applies toward your OOP Max amount. Look in your SPD to see if your deductible is included in the OOP max. Then it sounds like what they are saying is true (of course, assuming your doc/surgery center is in-network and there are no charges that are considered not covered due to other reasons in your SPD).

[kelking 0]

As emjay said you will want to either look at your SPD or talk with someone at the insurance company. I have been assigned a Case Worker within my insurance plan and she has been most helpful is managing the obstacle course that is insurance.

In my particular case, my deductible is $1500 and my max out of pocket is $4500. So I paid everything to my deductible 100% and then I paid 20% of all additional claims until I paid the additional $3000. From that point on, I will not pay another cent. One other thing you might want to understand is what effect out of network expenses have on all this. I know that I have an in network and out of network deductible. My sleep study ended up being out of network (I could kick myself for that one) so they applied 20% of the allowable amount towards my max out of pocket....even though my expense was much more than that.

I can all be so confusing, good luck in figuring it all out. If you have HR person or department you can go to, they might be of some help. You wouldn't even have to tell them what you were having done, just speak in general terms.

[Timoyal 0]

In my Insurance Coverage Booklet it says that all amounts paid as copayment an coinsurance shall count toward the maximum out of pocket and there will be no further obligation to pay coinsurance and co-pays after max out of pocket is reaction. But it doesn't say anything about my deductible. I'm so confused..:thumbup:.. I work for a very small from so no real HR person. I also have no out of network benefits, so everyone has to be in-network... I totally stressed out about all of this. OMG!, healthcare is a pain in the behind!!

Edited July 8, 2010 by Timoyal

[BetsyB 9]

It's really confusing, isn't it? My max out-of-pocket was $4500, I think (for the family). I had my surgery in January, and fully expected that would be my portion. Only I learned that because I'd chosen the insurance company's preferred Center of Excellence, this was waived. What a great surprise!

I was responsible for a $300 program fee (not covered by insurance; it covers a great deal of patient education, gym facilities, and other valuable things), and ---after my first 3 postop visits---a $30 copay for each visit/fill.

There were a handful of other incidentals--copays to the specialists needed for preop clearance,for example. No big shocks, though. (Well, other than the very pleasant surprise of having the whole deal paid for without the anticipated out-of-pocket payment!)

Totally doable--totally worth every penny. I think the whole deal cost me well less than $400. Now I am paying $30 a visit, plus whatever my Vitamins cost (I get them through my doctor so that I can get reimbursed by our flexible spending account.)

Do you have an HR benefits rep you can speak to? S/he can easily answer your questions and put your mind at ease.

I hope you get great news, like I did!