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(in the US) If I have a doctor that is not in my health insurance's network (and so listed as Not-Covered), or if my doctor prescribes a drug that is not covered, I understand the insurer will normally not pay the cost. However, if I have already paid as much as the annual out-of-pocket maximum for the plan isn't the plan responsible for all further costs (regardless of source)? Or am I always responsible for all out-of-network costs regardless of how much I've already paid this year?

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    There's no uniform answer to this question. The details will depend on your insurance policy. Some policies will have a separate out-of-network maximum (which may or may not combine with your in-network out-of-pocket maximum). Some policies (e.g. an EPO) won't cover you out of network no matter what (generally with some exceptions for emergencies). You'd have to contact your insurance company and/or your company's HR department (if you get your insurance through work) or carefully review the plan documents to understand your policy. – Zach Lipton Mar 2 '16 at 0:56
  • Hmmm, well there are 20 Gold options for my family in the Health Insurance Marketplace (no assistance, just looking for comparison). All are much cheaper than my current COBRA, but I'm worried if I switch I won't really have the coverage when going to most doctors or in an emergency. – Gary Mar 2 '16 at 2:04
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The portion of the billing that falls under the "allowed amount" will be captured by your out-of-pocket max, which may be different from your in-network out of pocket max.

This is the way it generally works assuming your plan has an out of network benefit. Considering an out of network 60% co-insurance; say you receive a bill for $5,000 from an out of network provider, for a service that is covered by your policy.

$5,000 Total Bill

$3,000 Allowed Amount

$1,800 Carrier portion of coinsurance (60% of $3,000)

$1,200 Your portion of coinsurance (40% of $3,000)

$2,000 Balance bill in excess of the allowed amount.

Your total exposure here are the bold amounts, $1,800 and $2,000. The $1,800 will be applied to your out-of-pocket max. The $2,000 balance bill is ignored by the carrier as it exceeds the allowed amount.

  • Ok, so if the policy annual out of pocket maximum is $2000, – Gary Mar 2 '16 at 21:01
  • (took me 5 min after I pressed enter), then the $1200 coinsurance that I pay applies toward that, leaving $800. So, will they pick up the $2000-800 (1200) of the "balance in excess of allowed amount" because once I've paid $2000 out of pocket, or is there really no limit to what I owe out-of-pocket if they decide that they only want to pay $3000 of the $5000. Why wouldn't they just say that the allowed amount is $1000 then? Is that regulated? – Gary Mar 2 '16 at 21:08
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    @Gary, if the procedure costs $1,000,000 and the "allowed amount" is $3,000 you will owe the $997,000 balance bill. The out-of-pocket maximums will only apply to amounts the insurance carrier will recognize. – quid Mar 2 '16 at 22:15
  • Ok, that's unfortunate, but thank you for the clarification. – Gary Mar 2 '16 at 23:08

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