1

Out-Of-Pocket Maximum is the amount you pay including any cost sharing payments such as coinsurance, copayments and deductible amounts. Usually copayments don't get counted toward deductibles and coinsurance kicks in after your deductible has been met.

Deductibles are any of out-of-pocket expenses for covered services that count toward your out-of-pocket maximum.

Its conceivable in a bizarre case of events that your copayments and medical bills can exceed your out-of-pocket maximum but your deductible may still not be met (even though it might be close).

What happens to the rules if deductible is not met but out-of-pocket max is met? Usually, insurance says they cover all benefits after deductible is met but I haven't seen an OR clause with out-of-pocket maximum. Perhaps I missed that somewhere in the legalease but it seems its implied that its either one that is met that all benefits are covered at 100%.

5
  • Are you assuming that you have out of network costs so that it you could hit the max before reaching you in-network deductible? Dec 14, 2021 at 21:24
  • No, just in-network only interactions in this hypothetical scenario. Based on the definitions I have been reading the definitions for the terms, it seems like its possible scenario if lets say the deductible and the out-of-pocket are the same for in-network providers.
    – LeanMan
    Dec 14, 2021 at 21:29
  • 1
    "Usually, insurance says they cover all benefits after deductible is met" not sure this is true, all the insurance plans I've had still have a co-insurance amount after deductible is met, and they only cover everything after out of pocket max is hit.
    – Hart CO
    Dec 14, 2021 at 22:20
  • Agreed. Its just that I see two plans with deductible/out-of-pocket max at $625/$625 and $800/$800, and the fact that not everything goes to deductible (for example co-pays) but copays do go to out-of-pocket max, so its conceivable you could hit the out-of-pocket max before hitting your deductible. This seems like a strange plan design. Wondering if this is intentional or is my understanding wrong somewhere. AND if it does seem like a strange plan design then it seems like the consumer is the one who has the advantage (which is fine by me :D).
    – LeanMan
    Dec 15, 2021 at 0:42
  • " Perhaps I missed that somewhere in the legalease but it seems its implied that its either one that is met that all benefits are covered at 100%." - I believe that's in ACA
    – littleadv
    Dec 15, 2021 at 7:11

0

You must log in to answer this question.

Browse other questions tagged .