Can someone explain maximum out of pocket?

[texmati]

The last time I spoke to our insurance, the lady mentioned that our max out of pocket doesn't include copays or deductables. How can this be? what else is there?

Our insurance has the following limits.

-they cover nothing until the 1000 dollar deductable has been met
-they cover 30 percent after that point
-max out of pocket is 2000 dollars per person

I thought this meant that the maximum that we would have to pay would be 2000 dollars out of our pocket.

But if they don't count deductibles, does this mean that we have to pay another 2000 at the 30 percent rate? We werent planning on getting pregnant this year, and the coverage is so horrible. We had the choice of quite a few insurance plans, but chose this one because the plan at my work would have cost 2000 a year more, so I thought we would be coming out ahead even if we hit the max out of pocket. But it sounds like that isn't the case?

[carmel23]

I hate how they refer to everything. Its BS. I don't think max out of pocket includes co-pays *or* "co-insurance," which can in some cases be up to 30 percent of a bill.

[Think of Winter]

That doesn't sound right. I would call again, and get the details of your policy in writing.

[Mosaic]

Ask for your "Explanation of Benefits" and it should explain it. Unfortunately, it's definitely possible that you could be looking at the $1k deductible plus another $2k per person, plus all copays.

[Calee]

Yes, this is most likely correct. Insurance so often stinks!

What this verbage means is that:

First, you will pay everything until you meet your $1000 deductible.

Second, you will pay your portion (30%) after the deductible has been met. The 30% is referred to as co-insurance, not a copay, so this money (anything you have to pay 30% of) should go toward your maximum yearly out of pocket.

After you pay $2000 out of pocket (in addition to your $1000 deductible), you will be covered 100%. (This is actually better than a lot of insurance I hae seen lately-many plans have $6,000-10,000 yearly maxes)

[texmati]

Originally Posted by Calee

Yes, this is most likely correct. Insurance so often stinks!

What this verbage means is that:

First, you will pay everything until you meet your $1000 deductible.

Second, you will pay your portion (30%) after the deductible has been met. The 30% is referred to as co-insurance, not a copay, so this money (anything you have to pay 30% of) should go toward your maximum yearly out of pocket.

After you pay $2000 out of pocket (in addition to your $1000 deductible), you will be covered 100%. (This is actually better than a lot of insurance I hae seen lately-many plans have $6,000-10,000 yearly maxes)

got it. The bolded part was what I was missing. It looks like I"m out more than I though. I know I should feel lucky, it's just that both years that we've gone the cheap route for insurance, we ended up getting pregnant. I know it doesnt matter in the long scheme of things.

[vbactivist]

Originally Posted by Calee

Yes, this is most likely correct. Insurance so often stinks!

What this verbage means is that:

First, you will pay everything until you meet your $1000 deductible.

Second, you will pay your portion (30%) after the deductible has been met. The 30% is referred to as co-insurance, not a copay, so this money (anything you have to pay 30% of) should go toward your maximum yearly out of pocket.

After you pay $2000 out of pocket (in addition to your $1000 deductible), you will be covered 100%. (This is actually better than a lot of insurance I hae seen lately-many plans have $6,000-10,000 yearly maxes)

we still have to pay our copays (for doctors visits and prescriptions) even after our max out of pocket is met. That is how we still end up paying between 10 and 20,000 a year in medical expenses.

So even after the max out of pocket is met , it doesn't necessarily mean that you won't be responsible for anything...