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California health insurance  -  Health insurance in California  -  Out of Pocket Max

The Out of Pocket Max for California Health Plans

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.

Different Names for The Same Important Benefit

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.

How does the Max out of Pocket Work?

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.

Key points on the Max out of Pocket

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.

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

Co-pay
Co-insurance
Deductible

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