You may think the silver lining of reaching your out-of-pocket maximum is that your insurance will now cover all of your healthcare costs. We’ve all thought it, and sadly, we’re wrong.
This post is a part of our 30 Days of US Healthcare series. You can watch all the videos in this series on YouTube and learn more about the content behind the videos here on our blog.
HOW CAN THIS BE? IT’S CALLED A MAXIMUM!
I know. Your pockets have been emptied out. You’ve paid your monthly premium, reached your annual deductible, paid all of the co-payments, and chipped in for your co-insurance. How can there possibly be anything more for you to contribute?
The thing is, your health insurance is only going to pay 100% of the costs of your COVERED benefits.
This means the out-of-pocket maximum doesn’t include things like:
💰 Your monthly premiums
💰 Goods and services your plan doesn’t cover
💰 Out-of-network care and services
Plus, if a provider charges you more than the amount that your insurance will allow, you must pay the difference.
BY THE NUMBERS
For workers insured in the US, 70% have a health insurance plan with an out-of-pocket maximum above $3,000.1
The 2023 out-of-pocket maximum for an Affordable Care Act plan can’t be more than $9,100 for an individual and $18,200 for a family.2
HEALTHCARE BILLING TIP
If you find yourself in a situation where you are being billed because you’ve been charged more than your insurance will allow, call your healthcare provider and kindly explain your situation. Sometimes your bill can be reduced to the maximum amount allowed by your health insurance provider.
1 “2022 Employer Health Benefits Survey – Section 7: Employee Cost Sharing.” KFF, 27 October 2022, www.kff.org/report-section/ehbs-2022-section-7-employee-cost-sharing/.
2 “Out-of-Pocket Maximum/Limit – Glossary.” Glossary | HealthCare.Gov, https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit.