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Oh wow. Blue Cross hosed that? Max Out of Pocket: This is the yearly maximum accumulation that an insured individual must pay before the insurer takes on full

Oh wow. Blue Cross hosed that? Max Out of Pocket: This is the yearly maximum accumulation that an insured individual must pay before the insurer takes on full financial responsibility for subsequent claims. This comes in generally one of two flavors: a family or individual. The individual is straightforward. If you have a MOOP of $1000, and you've paid out $1000 in copays or coinsurance after meeting your deductible on just you, you no longer owe any contribution on claims for you, for that year. However, someone else in your family on your insurance will have to have their copays/coinsurance paid until either their individual MOOP is hit, or between the two of you you accunulate enough for the family MOOP to kick in, which depending on the nature of the plan, will start covering expenses for everyone else in the family unit. Out_of_pocket_max is likely the individual MOOP. Max_out_of_pocket_max is probably a terribly named family or Group MOOP. These should not be confused with policy or lifetime maximums, which are caps to the amount of a specific benefit the insurer is willing to pay out for you as an individual period. I know for a fact places screw that all up. I spend a large chunk of time making sure things like that do not stick around.

monktastic1 5y ago
https://imgur.com/a/t7M2RGv https://imgur.com/a/t7M2RGv When I called, I was told that it's there to show that the OOP max for in-network and out-of-network providers isn't summed to get my total OOP max; instead it's just equal to my OON OOP max. (Of course, this plan makes it hard to go bankrupt, unlike all ACA plans. That was a bit of literary liberty.)
- salawat 5y ago
  Ah... So they're differentiating MOOP levels they'll honor based on the provider in question. I'm guessing they probably have some funneling arrangement that recoups the extra spend they'd incur from the potentially more frequent MOOP attainment in network. Cute, but it really kinda sidesteps the concept of "Max out of pocket". I sense an MBA at work.
  - monktastic1 5y ago
    Replying here because I couldn't respond to your other comment. All the ACA plans I've looked at pay nothing for OON, so in effect there's no maximum I may pay, right? I'm curious about this redlining solution. How do you decide how much you'll pay them?
    - salawat 5y ago
      Basically, you can just piggy-back essentially on your insurer's bargaining power by agreeing to what they would agree to pay +/- a percent on top. The provider can still refuse to provide service to the updated terms of course, but it puts the ball in their court, and insulates you from "surprise" bills. Just blindly signing it means exactly what is on that sheet of paper, that the provider settles on an amount, and you are accepting an obligation to repay it. Redlining and setting a ceiling on what you're willing/able to pay shows good faith. Which if it comes to a court case, goes a long way.
- Tijdreiziger 5y ago
  Excuse me -- your yearly deductible is $10,000? Here I thought €385 was a lot...
  - monktastic1 5y ago
    No, the deductible is much lower. This is the maximum I can spend out of pocket in a year. But most ACA ("Obamacare") plans have no maximum for our of network providers.
    - salawat 5y ago
      Actuallly... If it is an ACA plan, there has to be a MOOP. https://obamacarefacts.com/health-insurance/out-of-pocket-maximum/ https://obamacarefacts.com/health-insurance/out-of-pocket-ma... Now keep in mind, as mentioned earlier, if you go to an out-of-network provider, and get billed for the balance of what that provider charges and your insurance won't cover, that is now between you and the provider because the insurance claim is technically complete. This is why in some cases you may want to redline the financial responsibility statement and specify you will pay up to a set amount over what your insurer disburses. Technically, the provider can come back and grumble, but if you absolutely cannot afford to get nailed with a notorious "surprise" medical bill, that's a much more "good faith" way to approach the transaction. It sucks... I know.
  - akomtu 5y ago
    You probably pay way more in taxes. If I was given a choice between (1) an additional 20% income tax and free healthcare, or (2) crazy $10k/year out of pocket maximum, I'll choose 2 without a blink.
    - Tijdreiziger 5y ago
      At the risk of turning this into a political debate -- yes, you pay more taxes if you earn more, and less taxes if you earn less. That's how a society is supposed to work: you don't leave people to suffer because they aren't rich.
- jackthetab 5y ago
  > (Of course, this plan makes it hard to go bankrupt, unlike all ACA plans. Can you elaborate on this? I'm currently looking into ACA plans and would rather not go bankrupt...
pinko 5y ago
This is almost true: you will, in fact, be forever on the hook for any medical expenses charged which exceed the "reasonable" limits your insurer has set for each given service, even after you've exceeded your MOOP. So if your physical therapist charges $150/hour and your insurer reimburses $120/hour, you'll still owe $60 OOP for two hours of therapy even if you've exceeded your MOOP. Ask me how I know.
- salawat 5y ago
  Ah, but I bet if you look carefully, it's probably hidden in the EOB or benefit booklet somewhere, if not, somebody has dome writing to do. Even then, that is not a byproduct of the insurance, but of the "Consent to be treated and statement of patient financial responsibility" form that you almost certainly signed when you went to the doctor. That 120 dollars was still paid without coinsurance or copay from you after MOOP was attained, your physician is just falling back on what you signed to make up the difference. I hate medical billing to the point I dove in to try to figure out how it all works. Can you tell?
- OrlandoHakim 5y ago
  This happened to me and I found the practice extremely deceptive. In California it is nearly impossible to find therapy or similar services that don’t charge much more than the per service maximums allowed by Anthem Blue Cross (and likely others). This is primarily about out-of-network care, but good luck finding a competent therapist in-network in the Bay Area. For example, the max paid for a therapy visit might be $120 while the providers typically charge $160-180/session. On my plan, out-of-network providers were supposed to be 70% covered but I only learned after the fact that coverage was 70% up to the plan max for the stated service. How was one to know the plan max per service? Therein lies the trick, they won’t tell you until you are on the plan and even then you cannot simply ask for a list of limits by service. You have to ask one by one after you have already committed to the plan. The plan providers do not proactively disclose even the existence of these per service limits during open enrollment, and certainly not the detailed limits. The plan providers continue to do this year after year despite knowing full well that their limits are well below market rates. As a result predicting out of pocket costs for therapy or other mental health services is next to impossible. It feels fraudulent and deceptive even though I suspect they have excellent lawyers who keep them coloring just inside the lines so as not to get sued. Still, I sometimes wonder if a class-action lawsuit might be the best solution.

monktastic1 5y ago

https://imgur.com/a/t7M2RGv https://imgur.com/a/t7M2RGv When I called, I was told that it's there to show that the OOP max for in-network and out-of-network providers isn't summed to get my total OOP max; instead it's just equal to my OON OOP max. (Of course, this plan makes it hard to go bankrupt, unlike all ACA plans. That was a bit of literary liberty.)

salawat 5y ago
Ah... So they're differentiating MOOP levels they'll honor based on the provider in question. I'm guessing they probably have some funneling arrangement that recoups the extra spend they'd incur from the potentially more frequent MOOP attainment in network. Cute, but it really kinda sidesteps the concept of "Max out of pocket". I sense an MBA at work.
- monktastic1 5y ago
  Replying here because I couldn't respond to your other comment. All the ACA plans I've looked at pay nothing for OON, so in effect there's no maximum I may pay, right? I'm curious about this redlining solution. How do you decide how much you'll pay them?
  - salawat 5y ago
    Basically, you can just piggy-back essentially on your insurer's bargaining power by agreeing to what they would agree to pay +/- a percent on top. The provider can still refuse to provide service to the updated terms of course, but it puts the ball in their court, and insulates you from "surprise" bills. Just blindly signing it means exactly what is on that sheet of paper, that the provider settles on an amount, and you are accepting an obligation to repay it. Redlining and setting a ceiling on what you're willing/able to pay shows good faith. Which if it comes to a court case, goes a long way.
Tijdreiziger 5y ago
Excuse me -- your yearly deductible is $10,000? Here I thought €385 was a lot...
- monktastic1 5y ago
  No, the deductible is much lower. This is the maximum I can spend out of pocket in a year. But most ACA ("Obamacare") plans have no maximum for our of network providers.
  - salawat 5y ago
    Actuallly... If it is an ACA plan, there has to be a MOOP. https://obamacarefacts.com/health-insurance/out-of-pocket-maximum/ https://obamacarefacts.com/health-insurance/out-of-pocket-ma... Now keep in mind, as mentioned earlier, if you go to an out-of-network provider, and get billed for the balance of what that provider charges and your insurance won't cover, that is now between you and the provider because the insurance claim is technically complete. This is why in some cases you may want to redline the financial responsibility statement and specify you will pay up to a set amount over what your insurer disburses. Technically, the provider can come back and grumble, but if you absolutely cannot afford to get nailed with a notorious "surprise" medical bill, that's a much more "good faith" way to approach the transaction. It sucks... I know.
- akomtu 5y ago
  You probably pay way more in taxes. If I was given a choice between (1) an additional 20% income tax and free healthcare, or (2) crazy $10k/year out of pocket maximum, I'll choose 2 without a blink.
  - Tijdreiziger 5y ago
    At the risk of turning this into a political debate -- yes, you pay more taxes if you earn more, and less taxes if you earn less. That's how a society is supposed to work: you don't leave people to suffer because they aren't rich.
jackthetab 5y ago
> (Of course, this plan makes it hard to go bankrupt, unlike all ACA plans. Can you elaborate on this? I'm currently looking into ACA plans and would rather not go bankrupt...

pinko 5y ago

This is almost true: you will, in fact, be forever on the hook for any medical expenses charged which exceed the "reasonable" limits your insurer has set for each given service, even after you've exceeded your MOOP. So if your physical therapist charges $150/hour and your insurer reimburses $120/hour, you'll still owe $60 OOP for two hours of therapy even if you've exceeded your MOOP. Ask me how I know.

salawat 5y ago
Ah, but I bet if you look carefully, it's probably hidden in the EOB or benefit booklet somewhere, if not, somebody has dome writing to do. Even then, that is not a byproduct of the insurance, but of the "Consent to be treated and statement of patient financial responsibility" form that you almost certainly signed when you went to the doctor. That 120 dollars was still paid without coinsurance or copay from you after MOOP was attained, your physician is just falling back on what you signed to make up the difference. I hate medical billing to the point I dove in to try to figure out how it all works. Can you tell?
OrlandoHakim 5y ago
This happened to me and I found the practice extremely deceptive. In California it is nearly impossible to find therapy or similar services that don’t charge much more than the per service maximums allowed by Anthem Blue Cross (and likely others). This is primarily about out-of-network care, but good luck finding a competent therapist in-network in the Bay Area. For example, the max paid for a therapy visit might be $120 while the providers typically charge $160-180/session. On my plan, out-of-network providers were supposed to be 70% covered but I only learned after the fact that coverage was 70% up to the plan max for the stated service. How was one to know the plan max per service? Therein lies the trick, they won’t tell you until you are on the plan and even then you cannot simply ask for a list of limits by service. You have to ask one by one after you have already committed to the plan. The plan providers do not proactively disclose even the existence of these per service limits during open enrollment, and certainly not the detailed limits. The plan providers continue to do this year after year despite knowing full well that their limits are well below market rates. As a result predicting out of pocket costs for therapy or other mental health services is next to impossible. It feels fraudulent and deceptive even though I suspect they have excellent lawyers who keep them coloring just inside the lines so as not to get sued. Still, I sometimes wonder if a class-action lawsuit might be the best solution.