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View Diary: ACA: Understanding the details: Deducing the deductible; something you DO need to think about (65 comments)

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  •  Deductible PLUS Out of Pocket Maximum (6+ / 0-)

    I hope your series will include the Out of Pocket (OOP) Maximums as well.

    They are every bit as nasty and more incomprehensible imo than deductibles. So, let's say, you pay the $2500 deductible, then your insurance kicks in, right? Nope, it seems that that is where the OOP Maximum kicks in.  As I understand it, your reimbursement after paying the deductible will be a percentage of the total you owe up to the OOP maximum. After a dozen years on private insurance, I am still not entirely sure how these OOP Maximum provisions work. It is my understanding that if you meet the deductible, you are on your way to paying your OOP Maximum, but is the Deductible part of the OOP Maximum or is the OOP maximum in addition to the Deductible?

    I am looking for a formula for the total annual cost for my potential medical care. Is it: 1) Premium plus Deductible plus OOP Maximum plus Co-pays? or 2) Premium plus OOP Maximum plus Co-pays? or 3) Premium plus OOP Maximum, period? 4) Any or none of the the above.

    Medical expenses for me are going to be huge next year, so I want to figure out what is the best deal for me when considering all of the costs involved, including the premium. Is it worth it to buy a Gold plan if I am going to have the same OOP Maximum as a Bronze Plan?

    How does that work? And yes, I know I need to talk to a Navigator about this directly (and I will) but I don't think my situation is unique, so I am bringing it up here.  

    •  I think whether or not the deductible... (5+ / 0-)

      goes toward the OOP limit should be defined in whichever plan you choose but I have seen one plan in which it was not entirely clear. My existing individual policy has a deductible followed by co-insurance ant the OOP depends strictly on the amount I pay under co-insurance.

      Just another faggity fag socialist fuckstick homosinner!

      by Ian S on Tue Oct 08, 2013 at 03:15:55 PM PDT

      [ Parent ]

    •  I hope Araguato can answer (4+ / 0-)
      Recommended by:
      worldlotus, flo58, ladybug53, Araguato

      your question, flo58, because I am just as confused about the OOP Maximum as you are. And I'll bet there are many more folks in the same boat with us.

      BTW, THANK YOU Araguato for this fascinating series. I so appreciate it!

      "Long term: first the rich get mean, then the poor get mean, and the rest is history." My brother Rob.

      by Pat K California on Tue Oct 08, 2013 at 04:49:13 PM PDT

      [ Parent ]

    •  Oh, yes, (3+ / 0-)
      Recommended by:
      Willa Rogers, Pat K California, flo58

      I am planning to do an OOPs-installment in my series.

      In general Premiums don't count towards OOP, but deductibles, co-pays and co-insurance percentages do count.

      The cost you pay for any care provided out of network (and not covered by your plans OON benefit, if it has one) and any balance billing that resuts from same doesn't count. (Except as a deduction on your income taxes if it exceeds 10% of you income.)

      The OOP max is an annual thing (like the deductible) so if you know you're facing big health expenses get 'em taken care of early in the year.

      Any plan can probably differ from this scenario, but their details will have to be noted in their SOB.

      Get the SOB for any plan you're considering (they have to provide you one under the ACA). If the plan is larded with intricate weasel-holes, then don't buy it.

      It's a grand thing that individual buyers now have real choices instead of a take it or leave situation.

      Personally, I'm rooting for Adam Smith's (the 18th c guy) Invisible Hand to have a beneficial effect on the health insurance industry. Whether it just raises its middle finger or simply slaps some of these insurance companies around a bit, it will be quite refreshing to watch.


    •  Depends on the policy: (1+ / 0-)
      Recommended by:

      (Read your fine print)


      The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges, or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit. In Medicaid and CHIP, the limit includes premiums.

      Do notice it says "healthcare your plan does not cover." So if, for example, you go to a provider that isn't in your plan (and you have a plan that doesn't cover out of network providers), that cost you incur does not count toward the OOP limit. RX drugs the plan won't pay for similarly don't count.

      Only covered care counts.

      © grover

      So if you get hit by a bus tonight, would you be satisfied with how you spent today, your last day on earth? Live like tomorrow is never guaranteed, because it's not. -- Me.

      by grover on Tue Oct 08, 2013 at 11:20:41 PM PDT

      [ Parent ]

    •  Your other question (0+ / 0-)

      The one question you asked that I don't think the other responders addressed is whether it's worth paying for a gold plan over a bronze plan; that's going to depend on your anticipated healthcare needs.

      If the gold plan will pay 80% until you hit your OOP max while the bronze plan will pay 60%, but they have the same OOP max and you expect to hit it (and can afford to pay 40% until you hit the cap instead of paying half as much for twice as long), then (all else being equal) you might as well go with the cheaper plan.

      Whereas someone who doesn't expect to hit the OOP max either way might prefer a gold or platinum plan to reduce those OOP costs due to lower copays.

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