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California health insurance  -  Understand California health coverage  -  Life time Max out of Pocket

Lifetime maximum benefits and your California health plan

We have some good news on the life time max front. The new plans in California no longer have a life time max so although it's good to know (if you have some spare time and love insurance terminology), it's no longer a concern for legetimate carriers and plans. . This is an important part of your health plan and can quickly distinguish between a trustworthy health carrier and one that you may want to avoid. If you see a life time max on a prospective plan, it might be a good reason to run the other way. Let's take a look at the lifetime maximum in more detail to see why.

First, what's the official definition of a Life Time Max:

Lifetime maximum benefit (sometimes referred as lifetime limit)
A dollar limit on how much the insurance company will pay in your lifetime. An insurer may, for example, cover up to $5 million over your lifetime. Above this they will pay nothing.

More detail on the lifetime maximum

So it is a fixed amount that the carrier will pay up to during the lifetime of an enrollee (even over multiple, spaced-out polices). The lifetime maximum is usually per person in a family. There is a distinction between HMO and PPO plans with most carriers. Usually, PPO plans have a dollar amount such as the 5 or 6 million per person that was mentioned above. For HMO plans, however, it is not uncommon to have an unlimited lifetime maximum. Obviously, the higher the lifetime maximum, the better but truly catastrophic health conditions would be hard pressed to run even $1,000,000. Open heart surgery probably runs about $100,000 so you can see that $5,000,000 is more than adequate. At that point, you are just happy to be alive if you're even getting close to the maximum. On the flip side, a $100,000 lifetime maximum is not a good option. The whole point of health insurance (especially in today's medical climate), is to cap your risk or liabilities for a truly catastrophic situation. If you have $250,000 of medical expenses and the lifetime maximum is $100,000, that leaves you out of pocket for the additional $150,000. What's the point of having health insurance. Granted, the odds of having these large bills are very low but invariably, it does happen each year to a percentage of all plan enrollees.

Why is the Max Out of Pocket Important

The maximum is the amount that the carrier pays out of pocket. This does not include the deductibles, copays, co-insurance, etc that you are contributing as well. Your total medical bills may actually be much higher than the maximum when you take into account your out-of-pocket as well. This lifetime maximum is a separate number from your annual maximum which caps YOUR exposure for in-network and covered benefits during a calendar year. The two are mutually exclusive. The annual max protects you while the lifetime max protects the carrier. Again, this is very rare but in today's escalating cost environment and increasingly sophisticated technology landscape, it's not impossible to think that the maximum might be increased by the carriers going forward. For now, it is just a good litmus test for a carrier's strength and stability and a distinguishing piece to help choose the right plan.

Other important concepts to help you understand your health insurance quote are:

Co-insurance
Deductible

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