Preparing for Annual Out-of-Pocket Maximum Increases Next Year

Next year, plans sold on the Healthcare.gov Marketplace will be permitted to increase their “Out-of-Pocket” maximums to $7,900. What does that mean for you?

Out-of-pocket maximums are the amount set by a health plan that says, provided all medical costs are “in-network”, that once you pay that amount then the insurer will pay 100% of all in-network medical bills moving forward that calendar year. This can be a huge relief to someone facing catastrophically high medical bills, but uncomfortable for someone seeing only moderate number of bills
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Basically, most insurers require you to cover a “deductible”, where you pay 100% of medical costs up to that amount. After that, your plan will usually require either co-pays (fixed dollar amount payments) or coinsurance (a percentage of the incurred cost) depending on the service you receive, up until you hit that out-of-pocket maximum. Insurers can sometimes have separate out of pocket maximums for medical bills and for prescription drugs.

So what has changed? Next year (2019) plans will be permitted to increase their maximums up to $7,900 per person ($15,800 for a family plan), up from $7,350 in this year. That $550 difference is on top of changes in premiums and deductibles.

What can you do? To keep health costs down, we recommend the following:

1. Make sure you are going to an “in network” provider. Deductibles and Out-of-Pocket maximums can be even higher if you go to a provider outside of your insurer's list of who is preferred. Be sure to check! Doctors often don't know if the lab they recommend or the referral they suggest are in your plan's network or not. Most insurance companies will have a website feature or number to call to confirm.
2. Keep in mind what your expected medical costs next year might be when buying a plan. If you think you'll only have moderate expenses, less than the out of pocket max, you might want to consider a plan that features more co-pays (it will likely cost you less per procedure). But if you expect a lot of expensive medical visits next year, a plan with high coinsurance may have lower premiums and once you hit that out-of-pocket max the insurer will generally cover 100% of remaining in-network bills.
3. If a bill is wrong, challenge it! If you get a surprise bill saying it is out-of-network when you confirmed it wasn’t, call your insurance company or hospital billing department. Ask for clarification of the bill. Were you billed for a specialist but never saw one? Is your patient info correct? Were you billed twice for the same service? With a large deductible and/or out-of-pocket maximum, these bills will likely increase how much you must pay. Challenging bills is not always straightforward or easy, but doing so can save you on medical bills.

​Out-of-pocket costs can be a major crimp in your budget, especially when it is unexpected. Wisconsin Health Insurance Advocate LLC can be there to help you with these important health decision. WIHIA provides no-cost health insurance enrollment support for individuals and small groups, and we can also help you interpret (and possibly challenge) medical bills. Contact us here or call 414-797-3408!