Help - For Health Insurance, what does Max Out Of Pocket mean? (how much)

[sncoupons]

Could someone please help with this?

I have to select group health insurance with my new employer. One of the option they offer is where insurance company covers 80% of the expense and I would pay 20% of the expense. There is no deductible And, it says in-network maximum out of pocket per year is 1000. So, does that mean that if I use in-network service, even after paying 20% of any bill, I would never have to pay more than 1000 in a year?

In other words, if I get hospitalized, and get a bill of 50,000 from the hospital after paying co-pay for hospitalization initially, and then based on 80%/20% plan, insurance company would have to pay 40,000 and my bill 10,000. However, since maximum out of pocket for in-network service says 1,000. So, would it mean I still only pay 1,000 and insurance company pays 49,000 ? Am I understanding it correctly? Can someone PLEASE help!! I just want to make sure I don't make a wrong decision. HR of the company is not able to explain properly - she just wants me to select the 'high' option which has much higher premium but covers 100%.

[Keeper]

That is what it means, but $1,000 out of pocket max seems awfully low for that type of ins. at least from my experience with employer health ins. but they are all different. I would call the ins. company and ask them.

[lorriem]

We have a plan like that but the max out of pocket is $1,500. That was a life savor for us when hubby was diag with cancer. All we paid was the $1,500 that year and that included a 10 day stay and surgery at Moffitt and the 3 mos of Chemo at the cancer center near us. Plus it also paid any of the other doctors and tests when he was diag and all scans. I can't imagine how much we would have owed if we didn't have this plan. I do know it would have drained all of our savings plus some.

[duttygal86]

Max OOP means that your Coinsurance 80/20 goes up to 100%, this doesnt include copays/deductibles.

[lorriem]

Originally Posted by duttygal86

Max OOP means that your Coinsurance 80/20 goes up to 100%, this doesnt include copays/deductibles.

Ours did include copays/deductibles. That was once in 2005 and once in 2007.

[duttygal86]

I work for a Insurance company....it depends on your policy. Every year insurance companies rework the policies in order to have people pay more and more OOP. Usually you will have Copays no matter what.

[Keeper]

Originally Posted by duttygal86

I work for a Insurance company....it depends on your policy. Every year insurance companies rework the policies in order to have people pay more and more OOP. Usually you will have Copays no matter what.

So true.. they do change every year and you do have to read the policy carefully.

If you don't understand, call the company and ask just to be sure.