This term is relatively new to most California health insurance shoppers but it's probably the most important aspect of the policy that you'll consider. People are very interested in comparing copays and RX benefits but health insurance is reverting back to its origins of protecting against the big bills for the simple reason that it's too expensive to cover the smaller bills. The big bill speaks directly to the purpose of the max out of pocket. Let's understand what it is so we can choose wisely and potentially save money on our health insurance coverage.
First of all, there seem to be many ways to say the same thing. We're even guilty of interchanging the various name Copay Maximum, Out of pocket Max, Max out of Pocket, Annual Copay Limit, etc. They are refer to the same item. Basically, this number tells you how much you will have to in a calendar year for catastrophic bills (assuming in-network and for covered benefits). Let's run a quick example to make it easier.
Let's say we have a California health plan with a $1000 deductible, a $3000 max out of pocket and an 60/40 coinsurance split. Now, let's assume we have a $20K bill (which is a simple surgery in today's world). You would first pay the $1000 deductible. You then start paying 40% of the remaining charges until you the the $3000 max out of pocket. Depending on the plan and carrier, your true out of pocket might be $3K (if the max includes the deductible) or $4K (if the deductible is in addition to the max). We addressed this different way of showing deductible and max out of pocket separately. Either way, for that $20K bill, once we hit the $4K (assume latter), we're done for the calendar year. That's why we really have health insurance...not office copays for generic drugs. It's the big what if that drives the need for insurance and the market has been slowly getting back to that key point as rates exploded from richer, small dollar benefits.
The max out of pocket is usually per person, up to 2 people in a family. The numbers shown in the brochure and instant California health quote always assume in-network. You will pay considerably more if you use out of network providers in a non-emergency situation including the max out of pocket. Some plans have one number for both the deductible and max out of pocket (which is cleaner and generally lower) with this approach favored under HSA plan designs.
Once the max out of pocket is met, you should have very little out of pocket in-network for covered benefits for the remainder of the calendar year. The Max will reset Jan 1st regardless of when the policy started. There is no longer a lifetime benefit maximum (after which carrier would stop paying) on any the newer plans sold on the market and there is not an annual max for truly catastrophic health care needs.
Again, there is absolutely no cost to you for our services. Call 800-320-6269 Today!
YOU MAY STILL BE
ABLE TO ENROLL
In just 15 minutes:
With Existing Account
We can help you:
If Your Income
Is In This Range
Current Years Estimate; All those that file together on one 1040:
|Single Person:||$16k - $47k|
|2 People||$22k - $64k|
|3 People||$27k - $80k|
|4 People||$33k - $97k|
"My sincere thanks for making a miracle happen- 2014 health insurance !! Many thanks for your expertise and advice yesterday !!"
"Thanks again for your help - I had absolutely no idea how to get this done when I got up this morning. You've made it remarkably easier than I expected. I hope you're not stuck at the office all night..."
"Anyway, I hope you got some time off this past week! Thank you again for your help and efforts on my behalf! I was very lucky to find you."
"I thank you very much for the time that you have invested in handling everything
"I truly appreciate the quick response and will think of you in the future if I need to make any changes to my insurance plans."
"You are awesome... takes a huge worry off my back, thank you for your kind. thanks for your time and kindness. !!"
"Wow, I can't thank you guys enough for your help...I couldn't imagine trying to tackle this on my own!"
"You are my new best friend. A HUGE thank you again.
20 years of experience in the California health insurance market has taught us one thing...Competent and experienced guidance is Invaluable
We can quickly (very important) size up your health insurance needs and clearly explain the options available to you. Our focus is finding the most coverage at the best cost to you.
We are licensed Covered Ca agents with in-depth knowledge of their plans, process, and tax credits.
Call us...you will be Pleasantly Surprised. 800-320-6269
We'll quickly see if you have the best priced plan available and if you qualify for a tax credit800-320-6269
This website is owned and operated by Goodacre Insurance Services, which is solely responsible for its content. This site is not maintained by or associated with Covered California, and Covered California bears no responsibility for its content. The email address and phone numbers that appear throughout the site belong to Goodacre Insurance Services, and cannot be used to contact Covered California.