Help me understand out of pocket maximums

[Anonymous]

My healthcare plan’s out of network out of pocket maximum is $6k. To me, that sounds too good to be true - given all the stories you hear about people going bankrupt from hospital bills in the tens of hundreds of thousands. Are those people typically uninsured, or am I missing something?

[Anonymous]

We hit our out of pocket maximum last year. Everything was zero cost after that which was amazing. But yes, I’m guessing those stories are about people who are uninsured or have much higher out of pocket maximums or who use out of network care. We also have very expensive out of network care but the max out of pocket is separate and is $16,000 (of authorized amount which is not the billed amount.)

[Anonymous]

Sometimes there are loopholes in what counts toward out of pocket max. I have a child with a bleeding disorder. We have pretty good insurance 80/20 insurance with normal out of pocket max amount. However, we found out the $12,000/dose medicine my child needs doesn’t count toward our out of pocket max due to some insurance loop hole on how it gets categorized. Luckily our state offers extra coverage (bought for a fee) for special needs children, otherwise it could easily sink us.

[Anonymous]

Those people are uninsured OP. Also keep in my that the out-of-pocket max for in-network and out-of-network are two separate pots.

[Anonymous]

Some reasons here: https://blog.bernardbenefits.com/bid/196714/out-of-pocket-maximums-why-you-may-still-have-healthcare-expenses

[Anonymous]

In network out of pocket is still only at 80% of allowable charges and you eat that 20% as COINSURANCE with BCBS.

In other words if something is charged at $100 in network and that is the allowable charge, $80 goes to the deductible and $20 is "co insurance".

So your out of pocket maximum is not an actual maxiumum.

[Anonymous]

Anonymous wrote:My healthcare plan’s out of network out of pocket maximum is $6k. To me, that sounds too good to be true - given all the stories you hear about people going bankrupt from hospital bills in the tens of hundreds of thousands. Are those people typically uninsured, or am I missing something?

Uncovered expenses. They’re yours 100 percent, regardless of your OOP max.

[Anonymous]

Anonymous wrote:In network out of pocket is still only at 80% of allowable charges and you eat that 20% as COINSURANCE with BCBS.

In other words if something is charged at $100 in network and that is the allowable charge, $80 goes to the deductible and $20 is "co insurance".

So your out of pocket maximum is not an actual maxiumum.

No.

[Anonymous]

[Anonymous]

Only the “allowable amount” counts towards your OOP Max.

So for example, I see an out of network specialist. That doctor charges me $450 for an office visit. UHC’s “allowable amount” is $120. So only $120 gets counted, and I still owe the doctor $450.

I see this doctor frequently, and those $120 credits finally add up to $6,000. I’ve paid $22,500 out of pocket at this point. I go back to the doctor. Since I have hit my OOP Max, UHC covers the “allowable amount” of $120. I still owe the doctor $330.

This is an oversimplification, because there are likely deductibles and coinsurance involved. Also because it’s rare to just see a specialist that often and have no other medical expenses (lab work, prescriptions, etc). And as PP said, it’s a completely separate accounting than for your in-network expenses.

[Anonymous]

Then there's the OON doctor who participated in the 8 hour surgery you didn't even know was there. Or so I have read about.

[Anonymous]

Anonymous wrote:Then there's the OON doctor who participated in the 8 hour surgery you didn't even know was there. Or so I have read about.

Yep. So the allowable amount for that doc is $6,000. You have hit your OOP, but you owe that surgeon an additional $14,000. And then $330 per visit to follow up with her OON office.

This is how someone who makes a decent living, and has reasonable savings, and health insurance ends up with medical debt.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Then there's the OON doctor who participated in the 8 hour surgery you didn't even know was there. Or so I have read about.

Yep. So the allowable amount for that doc is $6,000. You have hit your OOP, but you owe that surgeon an additional $14,000. And then $330 per visit to follow up with her OON office.

This is how someone who makes a decent living, and has reasonable savings, and health insurance ends up with medical debt.

Wtf. This is so scary.

[Anonymous]

That’s called balance billing and VA just made it illegal.

https://scc.virginia.gov/pages/Balance-Billing-Protection

[Anonymous]

Anonymous wrote:In network out of pocket is still only at 80% of allowable charges and you eat that 20% as COINSURANCE with BCBS.

In other words if something is charged at $100 in network and that is the allowable charge, $80 goes to the deductible and $20 is "co insurance".

So your out of pocket maximum is not an actual maxiumum.

With BCBS, you don't even start paying coinsurance until you've reached your deductible. So if your deductible is $3000, you're paying 100% of that bill until you reach $3000. After that, coinsurance kicks in, and that 20% of the bill you're paying, goes toward your out of pocket max. No more deductible. So if your bill is $100, insurance covers $80, you pay $20, and that $20 of coinsurance counts against your out of pocket max.