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.
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.)
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.
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?
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.
I regret leaving my grandfathered plan from 2010 - every year I got a threat saying it would be gone next year, then magically one more 'extension' with a threat that it would be gone next year again. And the price kept going up. Switched to ACA plan and... I missed this 'no max' stuff. Fingers crossed I don't need healthcare if I'm ... you know, outside whatever 'network' might happen to take me in for care.
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.
We don't use tax money to bulk buy food, or auto repair, or fuel, or computers, or phones, or banking, or any other modern good or service that is essential and required for every member of society.
Why do we do it for health care or health care insurance? If the justification is "everyone needs it and you will die without it" then shouldn't farms and supermarkets also be public utilities? The line seems entirely arbitrary to me. Water yes, but food no? Why education and healthcare? Why not heating and electric power?
The added benefit of letting people arrange it individually is that those with a higher risk appetite are not forced into it (at significant personal expense) against their will/consent, too.
> We don't use tax money to bulk buy food, or auto repair, or fuel, or computers, or phones, or banking, or any other modern good or service that is essential and required for every member of society.
We certainly do: taxes fund social programs like welfare and subsidies, which allow every member of society to afford a baseline level of food, housing and transportation.
Back in World War II, food supplies were rationed precisely because everyone needs them, so food vendors have certainly faced regulation in times of scarcity. Farmers still receive sizable EU and US subsidies. [1] [2]
In the US, the government purchased bulk amounts of foods for decades. [3]
> We don't use tax money to bulk buy food, or auto repair, or fuel, or computers, or phones.
We don't buy bulk food because it's a commodity with low entry costs, and between subsidies and SNAP we can keep food almost universally available. We should be doing more, because people do fall through the gaps and our agriculture subsidies could be better directed.
We subsidize transportation and oil to keep costs down. We should do more to expand free at the point of access mass transit.
There are means-tested programs for cell phones paid entirely by tye federal government (you may hear them coloquially referred to as "Obamaphones").
Many people believe basic, low cost banking services should be provided through the USPS. I believe Senator Elizabeth Warren is an advocate for this policy.
> Why do we do it for health care or health care insurance?
Health care and health insurance are different from the other examples you listed. If a person is in dire need of care, they are unlikely to be able to shop around. They might not even be in a condition to prove they are able to pay, so we require hospitals to treat people without waiting for such proof, which means providers can take on significant losses which need to be covered.
And to keep costs down in such a system where you cover these cases, it makes sense to invest in preventative care, up to the point of paying people to get it.
Entry costs to starting a hospital or becoming a health care professional are high because people want some standard of safety. This lumits competition that makes your other examples work.
> Water yes, but food no? Why education and healthcare? Why not heating and electric power?
Yes to all of the above. Since you added heating and electric, often low income will qualify someone for assistance, eapecially heating in colder regions. Since the market functions well enough for people with sone money, means testing seems to work well enough here.
> The added benefit of letting people arrange it individually is that those with a higher risk appetite are not forced into it (at significant personal expense) against their will/consent, too.
The challenge is that if you make people arrange it individually, there is incentive to underestimate the risk (higher risk means higher premiums) and then they might need care that they cannot afford. The health care system sometimes still incurs this cost because they might have to provide emergency treatment (and many conditions untreated due to costs can become emergencies).
And at some point, perhaps you'll still get reasonable health care without it being tied to some employment (whether or not you were/are highly paid). Much harder to rely on that in the US.
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.
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.
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.
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.
That was my experience in fact. Therapists would participate in-network while young and inexperienced but would move out of network once they had more experience, a specialization, or a more established practice.
What that meant was if you had advanced needs you ended up paying out of pocket a lot.
Huh.
Ya know what? I'm going to go look through some paperwork to see if I can find regular omissions of that sort, because now that you mention it, that seems a rather glaring omission if true.
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.
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.