What or when you pay doesn’t affect your progress toward the out-of-pocket maximum (OOPM). You get credit toward the OOPM once the insurance processes the claim.
This is really confusing. To keep it simple: I’m $2,000 away from reaching my out-of-pocket maximum (OOPM). Should anything over that $2,000 be covered, even if I haven’t paid the $2,000 yet?
For example, I got a $2,700 bill from an endoscopy and then went to the ER after, where they gave me a $290 bill, saying it’s my 20% share. I haven’t paid the $290 because I thought it should be covered once I pay $2,000 towards the first bill to reach the OOPM.
Am I right, or do I owe the $290 since it was billed before I officially reached the OOPM?
I can’t figure it out, and if I’m wrong, I might be in trouble. I was in multiple ERs and admitted for several weeks, so if they submitted everything before I hit that extra $2,000, I could owe 20% of everything, which might be over $50,000 with all the tests they did.
Anything in-network over that $2,000 should be covered, as long as it’s not an excluded service (like IVF or weight loss drugs) and is medically necessary (not elective or cosmetic).
If the ERs you went to were in-network and the care wasn’t excluded or non-medically necessary, insurance should cover anything over $2,000.
For a true medical emergency (life-threatening or risk of losing a limb), you can go to an out-of-network ER, and the care will be treated as in-network because of the No Surprises Act. In a life-threatening situation, getting to the closest ER matters most, and you might not have time to check if it’s in-network. But if you went to the ER for something less serious (like a cold, twisted ankle, or headache), the No Surprises Act wouldn’t apply.
I think you’re overthinking this. How do you know you’re $2,000 away from the OOPM? Are you getting that number from your insurance’s website portal?
If that’s the case, check what claims your insurance has processed. Anything they’ve processed counts toward the OOPM, so you can set up a payment plan for those once they’re billed. Anything they haven’t processed yet (which you probably shouldn’t have been billed for yet) will also count toward the OOPM and lower that $2,000 amount. So, it’s best to wait to pay until you receive the EOB from your insurance.
Ok I THINK this makes sense lol. To answer your question yes I was seeing the $2k number on my online portal. I’ll just kinda wait and see what happens when all the bills start piling in.
You can check your online health insurance portal to see your year-to-date out-of-pocket maximum. Each Explanation of Benefits will show your “patient responsibility” or “what you owe” (for medical services and possibly prescriptions, depending on your plan), and these amounts add up toward your OOP maximum. You can add them up manually if you want to see if your total matches.
I usually compare the doctor or hospital bill with the EOB. If they match, I pay the bill. If you’ve already paid a copay at the doctor’s office, remember to subtract that amount from the EOB. It’s a good idea to create a filing system so you can keep track of what you owe and what you’ve already paid.