"Out of Pocket" maximum

[JAG10]

Does anyone have experience with a policy that has an "out of pocket" maximum cap for the year? We have a BCBS PPO, Personal CHoice and our "out of pocket" maximum is $2000/yr for an individual and $4K for the family. I guess I'm nervous procedures would be totally denied because if they are approved, then everything over $2000 must be covered, not what they deem "reasonable". Does anyone have any experience with this?

 

Sounds like a good thing except that pesky "pre-certification" part!

[airial95]

We have an out of pocket maximum for our insurance too, we haven't run into that problem so far, but then again, we aren't into IVIG or the like yet (thankfully the abx are doing the trick for us so far!) We have hit our out of pocket max every year for the last few years and haven't had any issues with them denying procedures. I think it's going to come down to how the Dr. orders are coded, but I'm not an insurance expert. I also went through something similar with my arthitis medication, after a couple months of (ineffective) treatments it was discovered that I had a rare, genetic form of arthiritis, not the typical RA. Initially, there was concern that the ins would deny the prescription since we hadn't gone through all of the typical "step" progressions through the other (cheaper) options. But since my dr. coded for something other than a type of RA, that hassle was avoided.

 

We're a bit different too because we don't have to get "pre-certified" for a whole lot since our ppo is self-insured. Don't know if this helps or not!

 

 

 

 

Does anyone have experience with a policy that has an "out of pocket" maximum cap for the year? We have a BCBS PPO, Personal CHoice and our "out of pocket" maximum is $2000/yr for an individual and $4K for the family. I guess I'm nervous procedures would be totally denied because if they are approved, then everything over $2000 must be covered, not what they deem "reasonable". Does anyone have any experience with this?

 

Sounds like a good thing except that pesky "pre-certification" part!

[thereishope]

I thought out of pocket maximum was the highest out of YOUR pocket.

 

How does your insurance work? Do you have a copay, 20/80, co-insurance, do you pay everything to a certain amount then get 100% coverage?

[JAG10]

It is the maximum amount out of our pocket, but I'm assuming that is only for approved and covered procedures. For example, our policy does not cover fertility treatments or plastic surgery, so if we chose those treatments, the insurance would not kick-in after we pass our maximum.

 

I guess what I'm wondering about is that the insurance company cannot contain costs by what they deem to be reasonable reimbursement once you pass your maximum, so the only other option, for them, is to deny the coverage of the procedure altogether as not being standard care of treatment.