You might be asking, well, what about my deductible? It’s excluded too.
My out of pocket maximum is $4,500 but I’ve actually had to spend more than $32,500 on healthcare this year. Not only am I currently paying for necessary care out of pocket but I no longer have related contractual protections from my insurance policy, such as limits on provider rates. Once that’s exceeded, not only do you have to pay out of pocket, you’re considered uninsured for any treatment of this kind. Legislators in each state write the laws which determine the local definition of “essential health benefits.” Of course, health insurance lobbyists play a role in how these benefits are defined.Īs an example, in Washington State, insurers limit outpatient rehabilitation to 25 visits. The website defines the Out of Pocket Maximum as “The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits.” That’s where the wiggle room begins for insurers. I’ve exceeded my out of pocket maximum yet am still paying out of my pocket for health care. After spending $12,505 in premiums and my share of covered services, I’m currently treated as uninsured when it comes to outpatient rehabilitation, physical therapy, chiropractic and soon, other services. Treatment related to my recently discovered brain tumor quickly pushed me over my out of pocket maximum for the year. Lifewise Plan Marketing for Out of Pocket Maximum