The BS of the concept of "out of pocket maximums".

[SparklyUnicorn]

I know we've talked about this many times.  People are often under the impression that such and such plan...the out of pocket max is XYZ so my costs will only be XYZ or somewhere around there.  NOT EVEN CLOSE. 

 

This year I've payed out of pocket $1765.12 so far (after insurance paid for the various services).  Guess which amount of that counts to my out of pocket maximum?  $575.38.  What is the point of claiming there is some sort of maximum?  Oh and add to that $60 because I went to an ophthalmology specialist more than once.  My plan only covers one visit per year.  That's right.  For whatever dumb reason they only cover it once.  And I absolutely need to go there. So next week that'll be at least another $60 (so now $120).  None of that will count towards my maximum either. 

 

Just venting... :glare:

 

 

[goldberry]

Yeah, it only counts toward OOP if it is an allowable service, or within the specified amount allowed by the insurance co for that service.

[SparklyUnicorn]

Oh no ALL of my services were allowable and in network (I did not count the ophthalmology in my example).  It's just that nearly all of what I'm required to pay does not count towards the out of pocket maximum!!!

 

 

[Greta]

Everything that medical insurance companies say is BS. Our insurance company claims "we pay 80%, you pay 20%". But what they mean is "we'll pay 80% of what we feel like paying, which will be roughly 40% of what you were charged."

[prairiewindmomma]

Preach it, sister.  I have the same d-n problem every freaking year.  

[G5052]

Yes, only if it's in-network and within their mysterious requirements that you only find out if you call ahead of time. Thankfully we live in an area with plenty of in-network choices and have the ability to choose.

 

We had around $50,000 of out-of-network billing this year, most of it unexpected but life-saving. Most providers will negotiate or put you on a payment plan.

Edited August 30, 2017 by G5052

[FaithManor]

If we assume that EVERYTHING is stacked against us when it comes to health insurance, and that insurance companies lie as naturally as breathing - ask me what State Farm tried to tell us about state law when we had our car accident and maintained FOR MONTHS until the attorney nearly strangled them - then we'll all at least be prepared for the shafting we are about to receive.

[G5052]

If we assume that EVERYTHING is stacked against us when it comes to health insurance, and that insurance companies lie as naturally as breathing - ask me what State Farm tried to tell us about state law when we had our car accident and maintained FOR MONTHS until the attorney nearly strangled them - then we'll all at least be prepared for the shafting we are about to receive.

 

Exactly. 

 

Even if you somewhat win, it will take months and months of certified letters and phone calls appealing it. If you aren't proactive with that, the provider will turn you over to collections. 

 

Or maybe you'll spend months and months trying to get someone to give in and no one will blink. Then you'll owe this huge bill. When you call the provider, they'll threaten to turn you over to collections unless you pay NOW because it's been so long.

[SparklyUnicorn]

Yes, only if it's in-network and within their mysterious requirements that you only find out if you call ahead of time. Thankfully we live in an area with plenty of in-network choices and have the ability to choose.

 

We had around $50,000 of out-of-network billing this year, most of it unexpected but life-saving. Most providers will negotiate or put you on a payment plan.

 

No but see that's the thing.  All of this WAS in network.  It is just that several things that I'm responsible to pay don't count towards the out of pocket max.  The copays, for example, don't count.  Neither does the deductible.  I think only the coinsurance counts (which is 15% for services that have a coinsurance). 

[QueenCat]

No but see that's the thing.  All of this WAS in network.  It is just that several things that I'm responsible to pay don't count towards the out of pocket max.  The copays, for example, don't count.  Neither does the deductible.  I think only the coinsurance counts (which is 15% for services that have a coinsurance). 

 

Oye, that's awful. Our deductible and the 20 of the 80/20 after meeting the deduct all apply to the OOP. We only have co-pays for one category but those have applied to our OOP (I keep a super detail spreadsheet so that I can keep track of all of that as things go through the claims process).

[SparklyUnicorn]

Oye, that's awful. Our deductible and the 20 of the 80/20 after meeting the deduct all apply to the OOP. We only have co-pays for one category but those have applied to our OOP (I keep a super detail spreadsheet so that I can keep track of all of that as things go through the claims process).

 

Oh yeah I hawk the claims.  I processed claims for several years so I know the ins and outs.  Today I was floored when I called to ask why a claim said I owed $60 (for something I thought should only have a $20 copay).  Turns out only one ophthalmology visit per year is covered.  WHY?!  What kind of crap benefit is that?!  Damn.  Stupid insurance.  At least I got the benefit of the contract discount.  So I guess that's something.  I am probably going to have to go back there a few more times though.  So yuck.

[Audrey]

Oh wow.  That's really awful.  I can't even imagine.   :sad: 

[AmandaVT]

No but see that's the thing.  All of this WAS in network.  It is just that several things that I'm responsible to pay don't count towards the out of pocket max.  The copays, for example, don't count.  Neither does the deductible.  I think only the coinsurance counts (which is 15% for services that have a coinsurance). 

 

That's not right. :-( I'm sorry! For our BCBS, prescriptions, copays, deductible all count towards our OOP for the year. Every plan should be like that! Grr. 

[FaithManor]

That's not right. :-( I'm sorry! For our BCBS, prescriptions, copays, deductible all count towards our OOP for the year. Every plan should be like that! Grr. 

And I wish that BCBS was like this in every state. Sadly they are not so there are states in wish your co-pays and in network OOP would not count towards the deductible.

 

That's the worst. National companies aren't really national when it comes to insurance which makes it a nightmare to figure out. And then some of them aren't even consistent from one region within a state to another. IT IS NUTS! But I truly believe it is designed to be that way so people end up paying way more out of pocket than their policy actually states because it is one more way to make more profit for the CEO and the wealthy investors with controlling interest.

[Spryte]

It is a nightmare.

 

We're at $38K OOP this year, and I can't understand for the life of me any of the nonsense that our insurance is citing to back it up. That $38K was prior to my current pneumonia - it's gone up since then. :(

 

They're not even allowing more than three pills per month for the antibiotics that are finally hitting the pneumonia. We just have to pay cash. Or I can stop the abx while we try for prior authorization but stopping for up to a week is not wise. If I pay cash, I can't do prior authorization because the pharmacy has to hold the Rx. So cash it is. Or CC as the case may be.

Edited August 31, 2017 by Spryte

[kewb]

I love when insurance companies say: Your doc submitted $500 in expenses but it is normal and customary in your area for doctors to charge $150. Therefore only $150 counts.

I would like to know where this plethora of docs in my high cost of living are that charge so little.

[marbel]

I noticed this when we had a copay plan.  I was always thinking we'd reached our OOP max, would call the insurance company and they'd say, oh no, this doesn't count, that doesn't count.  

 

But when we moved to a high-deductible plan, all that confusion went away.  We pay the full bill - after the negotiated rate is applied - till we fulfill the deductible. Everything applies to the OOP maximum, so I know exactly how much we will spend each year.  I like it so much better. 

[FaithManor]

I love when insurance companies say: Your doc submitted $500 in expenses but it is normal and customary in your area for doctors to charge $150. Therefore only $150 counts.

I would like to know where this plethora of docs in my high cost of living are that charge so little.

They don't exist. Figment of insurance imagination. They have studied the ways of Al Capone, and model themselves after him.

[Spryte]

We have a high deductible plan.

 

( I wrote above, and am elaborating, based on the advice to choose a high deductible plan.)  Our previous plan, when we hit the deductible, covered 100%.  It wasn't perfect, but it covered most everything we needed.

 

Currently, once we hit the deductible, they pay a portion of the in network (80%), then when we reach the OOP max - they supposedly pay more, though I can't get an answer on if it's then 100%.  We have paid out our deductible (almost $14K), plus $25K + and still they are not paying much.  It's unbelievable.  And, this plan is in the $26 - 30K range for our family, but that amount is paid by DH's employer.  So, yeh, I think we've paid quite a chunk for our insurance and not getting much coverage.

 

Our family spends $1200 per month on needed monthly meds with this plan - those are for 2 family members who need meds to breathe and stay alive.  That's our portion.  We've had 2 trips to the ER for anaphylaxis, one visit for an addisonian crisis that was managed without admission (miraculously), and some necessary specialist visits.  So - a busy year, but not a year with surgeries, major hospitalizations, etc.  

 

I am so disheartened.

 

 

 

 

[SparklyUnicorn]

We have a high deductible plan.

 

( I wrote above, and am elaborating, based on the advice to choose a high deductible plan.)  Our previous plan, when we hit the deductible, covered 100%.  It wasn't perfect, but it covered most everything we needed.

 

Currently, once we hit the deductible, they pay a portion of the in network (80%), then when we reach the OOP max - they supposedly pay more, though I can't get an answer on if it's then 100%.  We have paid out our deductible (almost $14K), plus $25K + and still they are not paying much.  It's unbelievable.  And, this plan is in the $26 - 30K range for our family, but that amount is paid by DH's employer.  So, yeh, I think we've paid quite a chunk for our insurance and not getting much coverage.

 

Our family spends $1200 per month on needed monthly meds with this plan - those are for 2 family members who need meds to breathe and stay alive.  That's our portion.  We've had 2 trips to the ER for anaphylaxis, one visit for an addisonian crisis that was managed without admission (miraculously), and some necessary specialist visits.  So - a busy year, but not a year with surgeries, major hospitalizations, etc.  

 

I am so disheartened.

 

Wow, that's quite awful!

[vonfirmath]

No but see that's the thing.  All of this WAS in network.  It is just that several things that I'm responsible to pay don't count towards the out of pocket max.  The copays, for example, don't count.  Neither does the deductible.  I think only the coinsurance counts (which is 15% for services that have a coinsurance). 

 

On our insurance, the deductible counts toward the Out of Pocket max. Co-pays do not, of course.

[vonfirmath]

Oh yeah I hawk the claims.  I processed claims for several years so I know the ins and outs.  Today I was floored when I called to ask why a claim said I owed $60 (for something I thought should only have a $20 copay).  Turns out only one ophthalmology visit per year is covered.  WHY?!  What kind of crap benefit is that?!  Damn.  Stupid insurance.  At least I got the benefit of the contract discount.  So I guess that's something.  I am probably going to have to go back there a few more times though.  So yuck.

 

Our insurance does not cover anything vision at all. No visits. No glasses. Nothing.

[SparklyUnicorn]

Our insurance does not cover anything vision at all. No visits. No glasses. Nothing.

 

I didn't go there for vision.

 

Turns out though, the doctor's office billed incorrectly.  I called them this morning, and they are resubmitting.  I hope it was as easy as that.  Ophthalmology IS covered on my plan, but routine is only covered one time per year.  I didn't go there for vision or a routine reason.

[AmandaVT]

I love when insurance companies say: Your doc submitted $500 in expenses but it is normal and customary in your area for doctors to charge $150. Therefore only $150 counts.

I would like to know where this plethora of docs in my high cost of living are that charge so little.

 

I'm wondering if this also varies by state - I do billing for a provider and we are required by our contracts with the insurance company to NOT charge the client beyond what the insurance covers. So we can charge $500 for a procedure all we want, but if the insurance only reimburses $150 for that service, we may not collect any additional fees from the client. When we sign a contract to be in network with the insurance company, we are agreeing to their reimbursement rates. Our clinicians could potentially be officially reprimanded or lose their licenses if they attempted to charge more. 

[marbel]

I'm wondering if this also varies by state - I do billing for a provider and we are required by our contracts with the insurance company to NOT charge the client beyond what the insurance covers. So we can charge $500 for a procedure all we want, but if the insurance only reimburses $150 for that service, we may not collect any additional fees from the client. When we sign a contract to be in network with the insurance company, we are agreeing to their reimbursement rates. Our clinicians could potentially be officially reprimanded or lose their licenses if they attempted to charge more. 

 

That's how it works with my insurance (I am in PA) and thought it was typical.  On my EOBs I see the provider's charge, and the amount the insurer will pay (the negotiated rate) and the amount I have to pay, which is also the amount applied to the deductible.  I am not responsible for the difference between the two.

 

So we have one provider who charges $150 for an office visit. The negotiated rate is $70.  I pay $70 till I reach my deductible/OOP max.  The provider writes off the difference, I assume.  

[Barb_]

Whether or not you pay above usual and customary depends on whether your provider is in network. If you have a few for service plan with no provider network, you don't have negotiated rates the provider has agreed to accept.

 

If you're going to an in-network provider and they're balance billing you, there is a problem with their billing department and you need yo fight the charges.

[RegGuheert]

No but see that's the thing.  All of this WAS in network.  It is just that several things that I'm responsible to pay don't count towards the out of pocket max.  The copays, for example, don't count.  Neither does the deductible.  I think only the coinsurance counts (which is 15% for services that have a coinsurance). 

And there is another "out of pocket expense" that most people seem to forget:  the massive, monthly premiums that you pay each month.  If you want to see what you have REALLY paid so far this year, be sure to included those premiums.

[Hikin' Mama]

I know we've talked about this many times. People are often under the impression that such and such plan...the out of pocket max is XYZ so my costs will only be XYZ or somewhere around there. NOT EVEN CLOSE.

 

This year I've payed out of pocket $1765.12 so far (after insurance paid for the various services). Guess which amount of that counts to my out of pocket maximum? $575.38. What is the point of claiming there is some sort of maximum? Oh and add to that $60 because I went to an ophthalmology specialist more than once. My plan only covers one visit per year. That's right. For whatever dumb reason they only cover it once. And I absolutely need to go there. So next week that'll be at least another $60 (so now $120). None of that will count towards my maximum either.

 

Just venting... :glare:

I liked your post, 'cause I agree with you. Health insurance drives me insane. Do you know how many times I had to do an accident report after I broke my leg and had surgery last summer? Four. Yes, four. I kept getting an explanation of benefits saying nothing was covered. When I called the insurance company to ask why, they told me I hadn't done an accident report. (Basically to see if they can get some other ins. co. to pay, which in this case they couldn't.) The last time I called, I told the person not to take it personally, but I was about to get nasty, because I pay a butt ton for insurance and have to keep calling to get them to do their job!!!! Aargh!

 

I won't even go into some of the other issues we've had, 'cause then my blood pressure will go up. 😡

Edited August 31, 2017 by Hikin' Mama

[Homebody2]

I won't even go into some of the other issues we've had, 'cause then my blood pressure will go up. 😡

Me too! I still get anxious when I get a bill from a provider because, in our case, most of the time there is an error that I have to push to get corrected. It has been unreal!

[StephanieZ]

Yah, insurance companies suck on every level. 

 

We desperately need to eliminate our reliance on private insurers for our medical care. 

 

Single payer, direct, universal, federally provided health care for all. . . Join me in my prayers and activism! 

[Crimson Wife]

No but see that's the thing.  All of this WAS in network.  It is just that several things that I'm responsible to pay don't count towards the out of pocket max.  The copays, for example, don't count.  Neither does the deductible.  I think only the coinsurance counts (which is 15% for services that have a coinsurance). 

 

That seems weird to me. All the policies we've had since DH left the Army counted the deductible and co-pays towards the annual out-of-pocket maximum.

 

It also seems weird to have a co-pay AND a cost-share for the same service. With our policies, we've either had a flat co-pay ($20-$100) OR a cost-share (10-40%). Not both.

[Crimson Wife]

I'm wondering if this also varies by state - I do billing for a provider and we are required by our contracts with the insurance company to NOT charge the client beyond what the insurance covers. So we can charge $500 for a procedure all we want, but if the insurance only reimburses $150 for that service, we may not collect any additional fees from the client. When we sign a contract to be in network with the insurance company, we are agreeing to their reimbursement rates. Our clinicians could potentially be officially reprimanded or lose their licenses if they attempted to charge more. 

 

You work for a provider that accepts insurance. More and more providers don't these days.

 

[MistyMountain]

OMG this is totally scaring me. We have been hit hard enough with two medical issues one of mine which quickly got us up to the OOP Max and one of my ds's which is not even covered and now they are saying it might take longer for him. If it ends up worse then the max I have no idea what we will do. :( the OOP Max was bad enough.

[Crimson Wife]

Yah, insurance companies suck on every level. 

 

We desperately need to eliminate our reliance on private insurers for our medical care. 

 

Single payer, direct, universal, federally provided health care for all. . . Join me in my prayers and activism! 

 

The only thing that was worse that all the costs and insurance hassles was Army healthcare. At least now with private we can get excellent care if we're willing to pay for it. Single payer would be cheaper but the quality would tank and there would be rationing.

 

As a society we need to do more to make healthcare affordable to low-to-moderate income families. I fully support expanding Medicaid to cover all low-income citizens and reimbursing deductibles & co-pays for moderate income citizens so that they do not exceed a reasonable % of income.

 

There are ways of helping people access care without getting rid of good private healthcare.

[Ravin]

Everything that medical insurance companies say is BS. Our insurance company claims "we pay 80%, you pay 20%". But what they mean is "we'll pay 80% of what we feel like paying, which will be roughly 40% of what you were charged."

 

This is the case when it's out of network "balance billing" on my insurance. If it's in-network, the provider isn't allowed to charge you more of what they feel like paying, so you only pay the 20% of what they feel like paying.

[Ravin]

The only thing that was worse that all the costs and insurance hassles was Army healthcare. At least now with private we can get excellent care if we're willing to pay for it. Single payer would be cheaper but the quality would tank and there would be rationing.

 

As a society we need to do more to make healthcare affordable to low-to-moderate income families. I fully support expanding Medicaid to cover all low-income citizens and reimbursing deductibles & co-pays for moderate income citizens so that they do not exceed a reasonable % of income.

 

There are ways of helping people access care without getting rid of good private healthcare.

 

Rationing based on actual need would be far preferable to rationing based on  willingness/ability to pay for services.

[scrapbookbuzz]

Oh yeah I hawk the claims.  I processed claims for several years so I know the ins and outs.  Today I was floored when I called to ask why a claim said I owed $60 (for something I thought should only have a $20 copay).  Turns out only one ophthalmology visit per year is covered.  WHY?!  What kind of crap benefit is that?!  Damn.  Stupid insurance.  At least I got the benefit of the contract discount.  So I guess that's something.  I am probably going to have to go back there a few more times though.  So yuck.

 

Is your medical insurance company getting optometry confused with opthamology, perhaps? The opthamologist is a medical doctor, and if he/she deems your visits medically necessary then the insurance company really should be covering that! I think someone (possibly many someones) at your insurance company needs to be educated!

[AmandaVT]

You work for a provider that accepts insurance. More and more providers don't these days.

 

 

I do - we also take cash pay clients. I thought the OP was insured. 

[Greta]

This is the case when it's out of network "balance billing" on my insurance. If it's in-network, the provider isn't allowed to charge you more of what they feel like paying, so you only pay the 20% of what they feel like paying.

Hm, that's interesting. Ours isn't like that. Even with in-network stuff, they pay 80% of what you would be charged if you lived in some hypothetical VERY low cost-of-living place, not 80% of what people get charged where you actually live. And the weird part is: we live in a very low cost of living place! So I think this magical place that they're basing their prices on is some small town in middle America in the 1950's!

[Barb_]

Hm, that's interesting. Ours isn't like that. Even with in-network stuff, they pay 80% of what you would be charged if you lived in some hypothetical VERY low cost-of-living place, not 80% of what people get charged where you actually live. And the weird part is: we live in a very low cost of living place! So I think this magical place that they're basing their prices on is some small town in middle America in the 1950's!

Yes, that magical rate is the rate they've negotiated with their in-network providers. If your provider is charging you over and above that contracted rate, there is a problem you need to get to the bottom of.

[Greta]

Yes, that magical rate is the rate they've negotiated with their in-network providers. If your provider is charging you over and above that contracted rate, there is a problem you need to get to the bottom of.

Thanks, I'll do so.

[QueenCat]

Our insurance does not cover anything vision at all. No visits. No glasses. Nothing.

 

Our health insurance doesn't unless it's an injury or illness. Our vision insurance, which is cheap, covers eye exams and glasses or contacts. We typically only end up paying about $150 for glasses that have all of the options on them (anti-glare, progressive, transitions, etc). I've never seen medical insurance cover the vision type stuff.

[SparklyUnicorn]

Our health insurance doesn't unless it's an injury or illness. Our vision insurance, which is cheap, covers eye exams and glasses or contacts. We typically only end up paying about $150 for glasses that have all of the options on them (anti-glare, progressive, transitions, etc). I've never seen medical insurance cover the vision type stuff.

 

We also have a separate vision insurance.  It's "ok".  More like a discount program than insurance.  Although it does cover an eye exam once per year ($10 copay).