By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"
Patient Advocate, Certified Mediator
AdvimedPro
September 2, 2024
Watch the video:https://youtu.be/XYVqtDGINDs
What is this "Out of pocket max"?
What should you know? What is the ugly truth? How to reduce it?
A. What is it?
it is the sum of your yearly "deductible" + "co-insurance" and usually "co-payments":
The "deductible" is a set amount that you must pay out of pocket first before your policy starts sending checks out to those medical providers who treated you. Each policy has a different deductible: some policies's deductibles are high (with low monthly premiums) others low (with high monthly premiums). Once that deductible has been met, your insurance starts making payments.
Once the deductible has been met, the "co-insurance" kicks in. This is a % set in the policy, which indicates what portion of the allowance you will pay and until what $ amount. If you consider that the "allowance" is the fee that the insurance has deemed is payable to the medical provider (either by contract if In Network or considered fair value if Out Of Network), then you pay a % of that fee and the insurance covers the rest, to a certain amount. For example: if your policy is 80/20, your insurance pays 80% of that allowance, and you pay 20%, until the amount set in the policy was reached. Once reached, the insurance starts paying 100% of every allowance until the end of the year.
Most policies will add "co-pays" in the Max Out of Pocket. A Co-pay is the set fee you pay every time you visit a doctor's office or ER department, see a specialist or get some other specific services, for example, a CT scan. Each policy will indicate how much of a copay you are responsible for.
2. It is also the limit that you can expect to pay for a year, as long as your policy is in effect, and you remain eligible.
There usually are 2 limits: one for In Network services and a higher one (sometimes double) for Out of Network services.
If there are 2 or more members under the same policy, expect that every member would have to reach their own limits before the insurance started paying 100% of allowances. A "family" Out Of Pocket Max would be reached - and all members' claims paid @ 100% - once 2 (sometimes more) members' maxes had been reached.
Some policies include Rx costs within the Out Of Pocket Max, others have 2 separate deductibles or max.
B. The bad news
The yearly maximum out of pocket does not reflect how much you will or could be eventually responsible to pay. Why?
Monthly premiums are not credited toward your Out Of Pocket max.
The $ applied towards your yearly max out of pocket are not the amounts billed by the medical providers, but the part of the allowances (which are either the contracted rate that a medical provider has agreed to accept as payment in full, or the fee that the insurance has determined to be a fair price for an out of network service) that is assigned to your responsibility (such as deductible, co-pay and co-insurance)
The difference between the amount billed by an In Network medical provider and the allowed amount is a write-off, a discount to you, an incentive and a reward for you using a preferred provider. But for out of network services, the difference between billed amounts and allowances is your financial responsibility. Even though you owe/pay it to the medical provider, you do not get credited for it.
Any amount "not covered" on your Explanation Of Benefits is not credited toward your max. Think of it as financial punishment because you used an out of network provider (even if not your choice)
Specific exclusions on your policy are not credited either: something that your policy does not cover such as alternative medicine, IVF, over the counter drugs, compound prescriptions, custodial care and more. If these items were billed to them, the full cost would be your financial responsibility, without getting any credit towards your out of pocket Max.
Items, services or treatments that are deemed experimental or investigational are not credited either. If the condition, diagnosis, medical need, clinical purpose, way of administration, frequency, dosage, prescribed use, is either not allowed or covered under the policy, not FDA approved or are not listed under the insurance medical policy as being safe, effective and therefore payable, and you want or need that treatment or procedure, it will be at your full charge with no credit again towards your yearly share of cost max.
C. Options and Solutions
So, can you change the out of pocket max? well, unfortunately, no. These amounts are set in stones, locked in a vault for the timeframe determined by the policy. So for one year (usually), as long as you pay your premiums and remain eligible, the terms cannot change.
But you can potentially increase what is credited toward it.
The easiest way is to use In Network providers, whenever you have the choice and the chance:
The highest possible part of an allowance will be credited, and if you have already met your deductible, the percentage of payment by the insurance will be the highest as well, saving you money.
You can locate contracted providers online. Choose the specialty, the gender of a doctor, language spoken, whether or not they have a qualification or the board certification you are looking for, and voila, a list pops up. You can also call the 800 number at the back of your card, for a list or recommendation.
2. Legal mandates
There are state and a federal law called the No Surprise Act, which protect you in cases of emergency, if out of network services are rendered at an In Network facility, especially if you don't have a choice of a provider (for example, pathologists, anesthesiologists, ER Drs).
3. Terms of policy
If a provider list given by your insurance is incorrect or not up to date, and you incur out of network costs, your insurance may be forced to pay the higher In network rate, and credit your Max with a higher $ amount.
If an Out Of Network provider has obtained a special authorization, at the In Network rate, your insurance must pay the higher rate, allow the highest allowances, and therefore credit you with the highest dollar amount.
A "Continuation of Care" authorization can also cover out of network services at the higher rate. It can/should be requested one when you start a treatment or get pregnant at the end of one year, and/or this care is rendered by a now out of network provider. Your plan would have to issue a special authorization to cover the time necessary for you to continue chemo treatment or have that baby, pay the higher rate, and credit you with a higher $ amount.
If you searched that In Network provider list, but could not find any available, trained, experienced provider who is willing and able to provide the medical service you require or address your medical condition, your insurance can be forced to pay the higher In Network rate and credit you the higher $ amount.
Stress "Preventive Care" whenever you go for your yearly checkup, take your child for vaccinations or well baby care visits, get a Pap smear, mammogram, colonoscopy, etc. When you make that appointment and at the time of the service, remind the receptionist, so that coding will be done correctly. Preventive Care is free. You do not need to pay any copay, you do not need to pay a deductible. You do not have any share of cost, but it must be coded properly by the medical provider.
In conclusion, while your yearly maximum out of pocket max cannot be changed, what can be is how much is credited towards it and how fast you can meet it so your insurance starts paying 100%.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2024 @ the medical bill whisperer 2024
Comments