I just called Anthem to find out my exact deductible, as I will be meeting it early this year. We have a high deductible, lower (smirk) premium plan. My individual defuctible is $6,500. I asked the gal in customer service if everything after that, mainly physical therapy and doc visits would be 100% covered. She said only if it’s an expense where you the deductible is met, but if there is an out of pocket amount I have to meet also, it wouldn’t be.
So, I asked what that was, she said $6,500. So, physical therapy wouldn’t be covered because I have to meet both. I said are you sure? I have to spend $13,000 to have 100% coverage? What the heck is the deductible for. She said something, honestly I was ticked. I don’t think she knows what she’s talking about.
If both my deductible and out of pocket are the same, that means I get the 100% coverage at that point correct?
Usually it will say something like you have a deductible of $6,500, and after that you have to pay a certain percentage of approved costs up to your out of pocket maximum (like $10,000). I’ve never heard of the OOP being the same amount as the deductible.
So you have to pay LESS after you meet the deductible, but you’re still paying some until you get to the OOP maximum. Yeah, it’s a racket.
Did she talk about a co-pay or co-insurance percentage? You have to first meet your deductible. After that you could still be subject to co-insurance (typically something like 80/20) until you reach your out of pocket max. The insurance should pay something after the deductible is met but that doesn’t always mean 100%.
I have a $3,000 deductible and $4,500 out of pocket max. I pay first $3,000. After that insurance company pays 80% and I pay 20%. After my costs hit the $4,500 ($3,000 deductible plus $1,500 from the 20% portion) the company would start to pay 100%.
Get online, you probably have an Anthem account where it shows your EOB, if you don’t have an such an account set up, consider doing it, my companies’ website is very useful. No way are you having to meet 13000 IMO. The reality is though, you don’t get unlimited physio, so that might be the tweak in question. Say you are given 25, they contribute to your deductible, but beyond that may well be out of pocket (but within service rate). If your OOP max is 13000, you will have that written somewhere. Find your account info, glossy brochure or online.
I have a high deductible. My deductible is $3000. Nothing is covered till I meet that. Then I pay a copay (I think it is 20%) till I meet my maximum out of pocket (which I think is $4500 this year - will change to Medicare in 3 months so I haven’t really studied the terms closely this year). The $4500 includes the $3000 so after I meet the $3000 I am on the hook for 20% of all my costs till I spend that next $1500.
I think it is unusual that the out of pocket max is the same as the deductible.
edited to add: Sounds like @123Mom456 and I have pretty similar plans
The maximum out of pocket is just what it sounds like: the maximum amount you have to pay, for all treatments and drugs that are covered by your policy.
So you have to pay a maximum of $6500 for all of your treatment. Note that this is only for treatments and drugs that are covered in network.
If you are prescribed treatments that your insurance does not cover, then you will have to pay for them and they don’t count toward your deductible. So, for example, if your doctor prescribes ten visits to a physical therapist, but your insurance only covers six, then you have to pay for the other four, and the cost doesn’t count toward your deductible.
If you get care out of network, the out of pocket maximum does not apply. Even if out of network care is covered under your insurance, the out of pocket maximum still does not apply.
Whether or not out-of-network counts towards OOP depends on your plan. I have two OOP maximum limits: one for in-network, one for out-of-network. When I hit the individual OOP for in-network, I then was covered at 100% for in-network. When I hit family OOP for out-of-network (IIRC, another $1500, covering both OON and other family member expenses), it was 100% for all of us. Charges above reasonable & customary don’t count in the totals.
Agree that there can be deductible and different OOP max. Only when your OOP max is met will most bills be paid, and only in-network charges. I don’t have deductible but met our OOP several times. Only after meeting OOP max does insurer pay 100%.
Ask for and read your policy. That will tell you your deductible AND any OOP max.
By law, your in-network out of pocket maximum must be less than $7350 for an individual, and $14,700 for a family, for any ACA-compliant plan for 2018.
There is no legal maximum for out of network care.
For this year, my last year’s policyhad a $6800 out of pocket maximum for in network care, and a $20,000 individual out of pocket maximum for out of network care. These were separate, so that in network care didn’t count against the out of network maximum, and out of network care didn’t count against the in network maximum.
So this particular policy pretended to be a PPO, but actually I could have been out of pocket $26,800. AND this policy cost almost $10,000 a year more than the next most expensive, for me and my husband.
I liked my old doctor, but not that much. We switched to a different plan.
I think you need to call back to reclarify. “She said only if it’s an expense where you the deductible is met, but if there is an out of pocket amount I have to meet also, it wouldn’t be.” If you meet your max OOP, this may refer to non covered expenses. Eg, you may hit 6500, but have some not-medically-necessary procedure done (or not approved,) it wouldn’t be covered. Or, as said, you exceed their max on PT visits. Or in some cases, in some states, your doctor refuses to accept the “negotiated payment amount,” which leaves you a balance due.
I think that might be what she was meaning @lookingforward . PT is not medically necesssary, so my deductible will probably not even touch that. Ok. I’m ticked now, I’m sure that’s it. This is so flawed.
If your MD prescribes PT and the PT gets pre-auth, most insurers will cover a certain # of sessions. There has to be more pre-autos requested for additional treatments. H has had PT at least did the last 6+ years and it has been covered. I believe there’s a cap of #/sessions/yr for each issue (more for stroke and less for shoulder surgery, etc).
He said he would do it if I wanted to go. Perhaps that’s considered medically necessary. I do know there are limits to what they will cover as for as how many sessions.
I have an Aetna high deductible plan. We (family deductible) have to pay the first $4K of regular (not preventative) expenses in full, though at whatever discounted rate Aetna negotiated with the provider. After we’ve met the deductible:
Rx drugs have a copy by tiers
PT has co-insurance with a limit of 30 visits per calendar year
Doctors/Hospitals have co-insurance
Once our OOP expenses exceed some amount ($7500?) then the plan pays 100%. However, if I’ve used up my 30 PT visits, it will not pay for additional visits, and Rx drugs are still limited by quantity and frequency.
Complicated stuff.
(My state does not require a doctor’s prescription for PT, but I learned that if I went to the PT practice affiliated with my orthopedic surgeon that I avoided all sorts of review.