If I’m on a high-deductible health plan with a $10,000 in-network deductible and $20,000 out-of-network deductible, is it possible to pay more than $20,000 in a year? For example, if a surgery costs $200,000, would the most I pay still be $20,000?
I’ve heard stories of people with insurance still ending up with huge medical debt. How does that happen? And how can I find out if something isn’t covered before a procedure?
Your out-of-pocket maximum (OOPM) is the most you’ll pay in a year for covered services. Once you hit that, insurance covers the rest, but this only applies to in-network and approved services.
Lane said:
Your out-of-pocket maximum (OOPM) is the most you’ll pay in a year for covered services. Once you hit that, insurance covers the rest, but this only applies to in-network and approved services.
This is true, but it’s only for services covered by your plan. If something is not covered, like an experimental procedure or out-of-network balance billing, those costs don’t count toward the OOPM, and you’d be responsible for them.
Lane said:
Your out-of-pocket maximum (OOPM) is the most you’ll pay in a year for covered services. Once you hit that, insurance covers the rest, but this only applies to in-network and approved services.
Be cautious with out-of-network care. Insurance only covers the usual and customary rate for those services. If the provider charges more than that, you’re on the hook for the balance, which can exceed your OOPM.
Look for the plan’s documents like the Summary of Benefits and Coverage (SBC) or the full policy document. These outline the maximum you could pay and what’s excluded from coverage.
For in-network care, your OOPM is the most you’ll pay in a year for medically necessary services. Out-of-network care can be trickier. If a provider charges more than the usual and customary rate, you could face balance billing, which doesn’t count toward your OOPM. For example, if a surgery costs $30,000 and insurance reimburses $10,000, the provider might bill you for the remaining $20,000.
If the service is covered and in-network, you shouldn’t pay more than your OOPM. However, services not covered by your plan, like cosmetic procedures or experimental treatments, can add to your costs. Always check coverage before agreeing to anything.
For my HDHP, the deductible and OOPM are the same amount, so once I hit $3,200, I don’t pay anything else. It depends on the plan’s design, so check your documents to confirm.
Your OOPM only applies to covered services. If your insurance doesn’t cover something, like a procedure deemed not medically necessary or a non-covered medication, your costs could go beyond the OOPM.
Tan said:
Your OOPM only applies to covered services. If your insurance doesn’t cover something, like a procedure deemed not medically necessary or a non-covered medication, your costs could go beyond the OOPM.
This is why travel medical insurance can be a lifesaver for things like helicopter rescues during hiking trips. It covers what regular insurance might not.
Tan said:
Your OOPM only applies to covered services. If your insurance doesn’t cover something, like a procedure deemed not medically necessary or a non-covered medication, your costs could go beyond the OOPM.
Some plans exclude certain medications from the OOPM entirely. My insurance requires copay assistance for specialty drugs, and those costs don’t count toward my OOPM.
Ask for the CPT and diagnosis codes for any procedure and call your insurance to verify if they’re covered. If prior authorization is needed, make sure it’s in place before proceeding. This can save you from unexpected costs.
Your deductible is what you pay before insurance kicks in. After that, you usually pay a percentage (coinsurance) until you hit the OOPM. For out-of-network care, you might owe more due to balance billing, which isn’t capped by the OOPM.
Horror stories often involve out-of-network care, lapsed coverage, or services not covered by insurance. If you travel, consider medical evacuation insurance. Some marketplace plans don’t cover out-of-network providers at all, so always verify coverage beforehand.
Out-of-network providers can charge more than the insurance’s allowable amount, and you’ll have to pay the difference. This is called balance billing and can lead to costs beyond your deductible or OOPM. Stick to in-network providers whenever possible.