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Did you ever reach your OOP Max? What Happened then?
Old 11-23-2014, 11:11 AM   #1
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Did you ever reach your OOP Max? What Happened then?

I'm deciding which HI plan to choose for my 2015 ACA policy. I'm currently considering a plan that has a $100 deductible, 10% coinsurance and a max out of pocket (OOP) of $500. (Five Hundred) Sounds pretty good, right?

I'm just a little paranoid about whether the OOP max will really protect me in the event of a major medical expense.


I know there are rules to be followed to make sure one does not incur a large bill for healthcare, as in the quote below, regarding the out of pocket limit, from Healthcare.gov :

"This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits."

I know there are many instances of people crossing all the T's and dotting all the I's, and still getting whacked, and having large expenses not covered.

Has anyone out there gone over the Max OOP and NOT been whacked up side the head by the provider and/or the insurer

Some positive stories would be reassuring!
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Old 11-23-2014, 11:43 AM   #2
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Yep: Ruptured my Achilles' tendon in Jan of 2013. Reruptured during recovery and had second surgery 4 weeks after the first.

Blew through the OOP max (6000 at the time) during the first surgery and the rest of my medical care was free to me the rest of the year. I'm fairly healthy, but I did take the opportunity to get some things checked out that I had been putting off.

Just make sure you're getting service from in-network providers, and you should be ok.

Beware of the complexities of medical billing - your surgeon and hospital might be in-network, but your anesthesiologist might not.
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Old 11-23-2014, 11:46 AM   #3
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Just make sure you're getting service from in-network providers, and you should be ok.

Beware of the complexities of medical billing - your surgeon and hospital might be in-network, but your anesthesiologist might not.
Yes, how did you handle this? Do you stay awake during surgery to make sure they don't sneak in some out of network attending surgeon who then balance bills you for $5k?
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Old 11-23-2014, 12:21 PM   #4
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Yes I did this year. Haven't paid a dime for in network care, since then. Perscriptions are $0, DRs visits as well including specialists. I haven't had the pleasure of being hospitalized since hitting max OOP but have no reason to believe in network stays would be any problem.

I have a choice to get treatment at a hospital run by a public company. As I understand it all DRs must accept the plans the public co. agrees to.

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Old 11-23-2014, 12:22 PM   #5
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If you do what the policy says, then the OOP max IS your max...

The big thing that I read about is people who go out of network for some reason.... and not always their fault... when my mom went to the hospital a bit more than a year ago, they brought in a cardiologist who was not in network... we did not know... we went to him as a follow up and the insurance refused to pay...


Note: the good news is that they did eventually pay after a year of back and forth...
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Old 11-23-2014, 12:23 PM   #6
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I hit my total out of pocket of $6250 this year. I'm careful to stay within network, so haven't had any issues with the insurer. All expenses incurred since that point have been paid by them.

If we had a single family policy instead of two individual policies I would have to pay much more this year.
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Old 11-23-2014, 12:32 PM   #7
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I hit my OOP max of $500 this year. One 15 minute doctors appointment and one 15 minutes ultrasound is all it took. My deductible was $500 so I paid the first $500 then the other couple hundred didn't cost me anything. Tried to think of some care I could get for free before end of the year but can't think of anything I need done. I guess that's a good thing?
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Old 11-23-2014, 01:26 PM   #8
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Yep. Fell and tore my rotator cuff in 2009. Had surgery. During recovery, stepped in a post hole when my husband moved a fence and didn't fill in one of the holes. Tore it again, even worse. I had met OOP on the first surgery, so second was free. And to top it all off, I had bought accident insurance through work for the first (and only) time ever. It paid $750 on both surgeries. So on the second, not only did it not cost me any money, I made $750. Although, I would have preferred not to go through that second surgery. Rotator cuff surgery is the pits.
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Old 11-23-2014, 02:13 PM   #9
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Good to hear so many positive replies!

What spooked me was the time I had a basic blood test done, using my current insurance. They refused to pay for a $6 charge for phlebotomy (the actual needle in vein blood draw). They said it was "not a covered service". What could possibly be more germaine to a blood test than the blood draw? And this was after I had verified everyone was in network, and the ins co said all I would owe was a $5 copay. So I have visions of other "not a covered service" scenarios in the future, which I would have to pay even after reaching the OOP max.


But good to know others have had good results with the OOP max.
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Old 11-23-2014, 03:52 PM   #10
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Yes, how did you handle this? Do you stay awake during surgery to make sure they don't sneak in some out of network attending surgeon who then balance bills you for $5k?
I wish there were a good answer for this one, but I think the best you can do is to cross your fingers and hope.

In my case, I was able to confirm in advance that anesthesia would be in-network, but there's always a chance that something slips through.

The thing that makes it frustrating is that nobody is watching out for this - the people who decide who will be involved in what procedure generally seem to know as little about the billing side of things as the typical patient. So what will get charged is just not a factor in any decisions they make (and some decisions might have a huge billing impact).

Nonetheless, I do believe that the vast majority of cases go smoothly - it's just that in the cases where something goes wrong with billing the impact can be extreme.
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Old 11-23-2014, 03:55 PM   #11
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Good to hear so many positive replies!

What spooked me was the time I had a basic blood test done, using my current insurance. They refused to pay for a $6 charge for phlebotomy (the actual needle in vein blood draw). They said it was "not a covered service". [...]
I'm curious about this one. It is my impression that with the standard terms for the majority of plans, if a provider is in-network, they can only bill you for covered services. If something is not allowed, the provider has to eat the charge - they're not allowed to charge you for the excess (despite this fact, I've read that it is still a common practice to attempt to bill patients, but a quick call to the provider will almost certainly fix that).

This does not generally apply to out-of-network charges, which is one of the reasons to be very careful about staying in network.
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Old 11-23-2014, 04:10 PM   #12
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I had a half day of specialized testing. The provider sent me some information said to call your insurance to check. I did that, BCBS checked for me. I knew in advance what my cost would be.

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Old 11-23-2014, 04:31 PM   #13
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Quote:
Originally Posted by John Galt III View Post
I'm deciding which HI plan to choose for my 2015 ACA policy. I'm currently considering a plan that has a $100 deductible, 10% coinsurance and a max out of pocket (OOP) of $500. (Five Hundred) Sounds pretty good, right?

I'm just a little paranoid about whether the OOP max will really protect me in the event of a major medical expense.


I know there are rules to be followed to make sure one does not incur a large bill for healthcare, as in the quote below, regarding the out of pocket limit, from Healthcare.gov :

"This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits."

I know there are many instances of people crossing all the T's and dotting all the I's, and still getting whacked, and having large expenses not covered.

Has anyone out there gone over the Max OOP and NOT been whacked up side the head by the provider and/or the insurer

Some positive stories would be reassuring!
How big is their network? Make sure there is not a separate deductible for prescription drugs. $500? Sounds to good to be true.

I have a $7000 catastrophic, includes prescription drugs. Met it in July due to my son's medical condition. Haven't paid a dime since. Took me about a month of checking the EOB's I received looking for my co-pay amounts, kept being $0.00. I am finally now relaxed about it.
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Old 11-23-2014, 04:39 PM   #14
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The year I had back surgery I met the OOP max of $5k, and later that year DW needed surgery which cost us nothing.
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Old 11-24-2014, 10:38 AM   #15
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Not retired yet. The Bronze HSA EPO plans that I am checking for 2015, all have OOP around $12,500. Most of you have much better HI that I can find.
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Old 11-25-2014, 10:16 AM   #16
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One other risk beyond defending against out of network services is general foot dragging and misdirection on the part of your insurance company.

From my perspective, it seems as if BlueCross NC has managed to deny claims (or at least delay claims) that are valid once they started having to pay. In other words, when I was paying and building toward the OOPM, there was no problem (claims got accepted and recorded quickly), but now that they're paying, there are a few claims that have become a problem and are still being considered (for MONTHS!). Good thing the provider is being patient and not charging me interest. Well, they've removed the first interest charge, anyway.
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Old 11-25-2014, 10:22 AM   #17
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I wish there were a good answer for this one, but I think the best you can do is to cross your fingers and hope.

In my case, I was able to confirm in advance that anesthesia would be in-network, but there's always a chance that something slips through.

The thing that makes it frustrating is that nobody is watching out for this - the people who decide who will be involved in what procedure generally seem to know as little about the billing side of things as the typical patient. So what will get charged is just not a factor in any decisions they make (and some decisions might have a huge billing impact).

Nonetheless, I do believe that the vast majority of cases go smoothly - it's just that in the cases where something goes wrong with billing the impact can be extreme.
Blue Cross Blue Shield Texas has a web page where I can look up the hospitals in my area and see how many have out-of-network anesthesiologists and other physicians (such as pathologist or radiologist). It's given in %. Far better than nothing!!!
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Old 11-25-2014, 12:45 PM   #18
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I did reach the out-of-pocket max a couple years ago with our large HMO. The major changes were that the statements we got showed the charge for each service to be fully paid by insurance with the patient's portion at $0.00, and the clerk stopped asking for copayments when we checked in for a visit.. Other than that, nothing else changed.
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Old 11-25-2014, 09:50 PM   #19
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I met the max when I had my daughter then again this year due to a surgery. Both times, the insurance company paid everything at 100% until the end of the calendar year. Since I reached my max this year, I have various check-up appointments and tests scheduled for December which will be no cost to me.
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