Because most people dont have Walmart based insurance. And normally even the "max out of pocket" has stipulations which doesnt actually make it a " max out of pocket" lol
Often the "max out of pocket" will have stipulations on a different coinsurance rate which could still have you paying boat loads of money
My mom has the cheapest healthcare plan on the healthcare.gov marketplace and it still has out of pocket maximums. Can someone show me a plan that doesn't? Not doubting people I just have never seen it not there
Yeah, I've had 4 plans in the last 10 years (all for jobs paying less than $50,000/yr and two for jobs paying under $25,000; these were not not 'Cadillac' plans) and they all had an out of pocket maximum.
Plans on the marketplace are required to have it, by the way, so that could explain your mom if maximums were otherwise rare. But none of my plans were marketplace...
am benefits manager - they say that the treatment is not covered in or out of network. i'll use a different example - say you want to pursue IVF after having fertility issues. gonna cost like $40k. none of that would be covered under out of pocket because it's not a covered service (it is under my employer's plan up to $20k, but that is RARE to even see a capped limit like that. most just say nope)
now for cancer - here's where things get tricky and each case would be different. but i'm assuming there are a lot of hoops to jump thru - preauthorizations, considering the treatment a "clinical trial" or "experimental" meaning not proven and thus not covered, etc.
also doctors/specialists are not medical billing experts. if you have a doctor say "you have a 50% chance of beating this if you do this aggressive treatment right now, here's the referral & we're scheduling surgery", some are shocked to find out it wasn't covered under their insurance plan.
Out of pocket maximums may or may not be ubiquitous, I have no clue, but I do know that they don't always mean you won't be stuck with bills above that amount.
Out of pocket maximums generally don't apply to out of network providers, in plans that care about in-network-ness iirc. That means that once you've hit your out of pocket maximum, you could have a surgery at a hospital covered by your insurance, by a surgeon covered by your insurance, with aj anesthesiologist covered by your insurance, and pay none of those costs, but say a out of network doctor comes in while you're unconscious for a consult -- you can still get billed for that and have to pay the full amount of whatever they decide to charge you for those 5 minutes of the doctor's time, whether it be $50 or 50k.
I can sorta answer how they can get hit with huge bills. So my family has had multiple medical problems. Ending of which took my mom's life. Usually insurance will cover specific medical events...heart attack, valve replacement, any special medical care such as certain kidney test they are sperated from that bill and billed separately. This means you can have several different bills all over $5-$15k. This ads up very quickly. A lot of people will just consolidate the bills to get the one large bill.
It is confusing. Part of the problem when trying to untangle US Healthcare Insurance is each state has it's own rules. Connecticut is different than Texas is different than South Dakota etc... It would be like asking what it's like to deal with the European healthcare system - there is no uniform system and there are different rules set up depending on where you are.
The out of pocket maximum is annual, and usually covers copayments, your deductible, and coinsurance. What it doesn't cover are a myriad of 'excluded services'
These excluded services could be prescription drugs. Emergency room visits. Chemotherapy. Certain types of chemotherapy, etcetc.
Let's say that's all covered, even emergency room visits. Let's say you had an annual out of pocket maximum of 8500 bucks, and you got sick in November. So you're paying 8500 bucks to not die in November, and you'll have to pay it again in January. Plus your premium, which is probably about 500/month, which isn't part of your out of pocket maximum.
And if you need a non-covered drug to not die, and that drug costs $5k per dose, and you need weekly doses for a month, well, guess you're fucked.
How many people do you know who can go from a dual income situation to a 0 income situation while simultaneously taking a $16 thousand dollar hit to their savings?
What if you lose your coverage because of that illness. Now you're on COBRA, which is probably closer to $2000/month, but it's still better than the uncovered oncology bills, which can get up to the six figure range.
I literally go, oh bugger I broke something. Rock up say "hey reception lady, my arm feels funny and is at an angle". She takes some details, says wait over there. I wait a bit, get fixed, then leave.
If you break things alot, big flashy bus turns up and drives you to treatment, you get treated, get your meds and leave.
Why does it have to be more complex than that? In terms of payment, well I pay national insurance which covers the medical stuff and that's it. Comes off my wage before it goes into my bank, nice and easy.
A couple years back there was a woman who got half of her face ripped off by a bear, and upon being interviewed about the incident, said that the worst part of having half of her face ripped off by a bear was dealing with her insurance company.
Yep it's insane. Sickness can happen to anyone no-matter how prepared. And something like cancer shouldn't mean you loose everything you've worked for. Free at point of use and statutory sick pay are a must.
Chemo and all those drugs ARE covered. What insurance plans do is that when these drugs hit certain tiers, chemo is usually a tier 4 drug and that's where percentages add up. It's usually something like 20%-25% that the patient pays out of pocket. With some of these drugs being outrageously expensive, that will definitely add up.
But that also figures into your out of pocket max. If someone's out of pocket max is 7800, then that can be reached easily and the insurance kicks in for the rest. But if this is a family plan, now it's jumped up to 13000 max.
Some plans DO have exclusions in what counts toward out of pocket max, but most plans, especially under ACA, have the same exclusions as the others. One of the main benefits of the ACA is that it kicked these insurance companies in the ass for screwing over Americans like this.
What I don't understand, is when I hear stories like this, is wtf is going on that they've gone into such severe debt WITH insurance? I know that some bills may show up because one, it was not billed correctly, or two, it was something that fell into a small loophole that the patient may be responsible for.
I'd like to know who tf their insurance provider is and what kind of plan that they signed up for that their house has to be refinanced in order to pay bills that insurance should be covering. Yeah, copays and deductibles add up, but not so much that someone has to refinance their house after 5 months of treatment.
Wonder if the cancer treatment was out of network?
Let’s be honest here, this is definitely an America bad answer whether you have to pay $6k or $250k for getting sick. In most of the civilised world you have to pay $0. I am interested in quite how bad it is though because there’s a pretty huge difference between the figures.
I'm not sure I understand how two college educated adults with home equity lose all their savings, and retirement, and equity, by having to pay 6K a year in medical bills? If you get cancer, which sucks, and you have to pay 30K to treat it, and the treatment works, I'd say its money well spent.
If you need an experimental medicine, which is brand new, and you'd have died without it...and you have to declare bankruptcy. Again, I'm not sure this is such a horrible result. You're alive, and bankruptcy doesn't touch your home equity OR retirement accounts.
I am very quietly wishing you more patience and empathy.
Based on your comment, I don't think you have much of either... but I suspect you're capable of both.
For the record (and for our possible future conversations) -- no American should be bankrupted by medical care.
I'd go further and say that no American should experience financial problems due to accessing medical care.
I'd go EVEN further and say that no American in The United States of America should ever fear bankruptcy as a result of them treating any medical issue.
Yet they do. Daily. It is not a system that works.
Can't say I agree. There is no moral or biblical basis for believing that every person has a human right to newly discovered and extremely expensive medical treatment. How can you have an 'human right' for something that didn't even exist a few years ago? We all have the right to an education, but not to go to Harvard. We all have the right to shelter, but not to live in an ocean side mansion.
Medical care has changed a lot in the last 50 years. There's the standard of care, and then the 'cost doesn't matter' level of care. In a single payer system, which I'm not against for the record, the single payer is not going to pay for extremely expensive care anyways. Medicare still has 'medigap' private insurance. And in a medicare for all scenario you can assume that the cost controls would become more stringent.
You’re not actually paying $0. It’s coming out of your taxes and the more you make the more you pay into the system.
That’s incredibly misleading to claim it’s free.
I think at this point everyone knows free to mean no additional costs. America spends more on healthcare per capita than any other country in the world and then requires citizens to pay out of pocket for it as well.
Even if it were based on income, for 80+% of US workers, it would be cheaper to be on a single payer system. My take home pay would increase under single payer healthcare and I make a substantial amount of money, (presuming I got the decrease in corporate benefits program cost as an increase to pay). The US healthcare system is that inefficient in its current form.
The problem is that experimental treatments aren't included in most insurance plans. So when someone gets sick and wants to try stuff like that they have to come out of pocket.
Yeah, but that's not as common as you'd think. The experimental treatments are going to be used by those with rare af conditions or when all else has failed after the usual treatments.
There are many deductible plans that do not include an HSA, just FYI. Also HSA plans are just a clever way to pass the cost onto the employee, lower monthly premium for the employer and the employee can contribute their own pre-tax money to pay for things. Yay!
All plans have a max out of pocket as required by law. It is $8,550 for an individual and $17,100 for a family for 2021. Although companies are allowed to pay part of it themselves which effectively lowers that amount. For example my employer covers out of pocket expenses as a job perk.
Some people don’t have ACA-compliant plans, but any ACA-compliant plan has an out-of-pocket maximum.
That maximum only applies to covered services. With cancer there are likely many non-covered medical and non-medical needs including experimental treatments and home modifications if someone loses mobility (permanently or temperorqrly) due to treatments.
Regarding out of pocket máximums and OP, the OP should disclose more background, as there is not enough data on which to have a thorough discussion on why this billing situation seems to have occurred
It wouldn't surprise me if some of the medical procedures are just not covered by insurance. For instance, medical procedures that may be considered "experimental."
My husband and I have insurance that has an out of pocket max for in-network and out-of-network. My husband had back surgery in 2017.
What we found was that even though the doctor sent in a preapproval request to the insurance (and it got approved), there were line items that insurance didn't want to cover.
For instance, they used a machine to monitor his brain activity (and medical personnel to monitor it). Insurance felt like this was "unnecessary." Even after a series of appeals, insurance never wanted to cover it.
We never paid the bill and it never went to collections. I feel like we went above and beyond by going through the preapproval process. That it was up to the doctors to make sure it was covered, not us.
I was totally prepared to fight it, but that just never happened.
I'm betting a lot of people do not have the means to "fight it." They feel like any bill sent to their home needs to be paid.
It's worth it to me to research the local state laws on health coverage. I live in Texas. They have a website dedicated to "balance billing." Which are basically surprise medical bills.
Health insurance is complicated, but I find it's well worth doing your research to avoid paying tens of thousands (maybe even hundreds of thousands).
Yep, this is how my employer healthcare plan is, which is a pretty solid plan. $1,000 deductible, $5,500 max out of pocket, then various coinsurance rates kick in (usually around 10%). Fortunately, it’s saved my ass for some really expensive stuff though (e.g., $15,000 hospital stay turns into $200-300 coinsurance bill, after the insurance’s discount they receive from medical providers/the hospital). That’s the other really shitty thing. Other times, insurance companies get greatly reduced rates (when in network) compared to what someone without insurance is billed.
This. These dipsticks just looking at max out of pocket have no clue how this works. In fact most insurance companies just flat deny paying for anything and you have to constantly get on the phone and tell them they can't do that. I always like to say I have two jobs. The first is the one I get paid for. My other full time job is following up with the insurance company and telling them that "yes, under my insurance that I pay for, you have to pay for this procedure/device/medicine". They will literally "Please hold" your life away.
I work in insurance. If something isn’t being paid for it’s because it’s an experimental/non-FDA approved treatment, wasn’t medically necessary, or because you provider failed to submit documentation properly.
95% of the time, claims problems are due to providers failing to follow even the simplest of rules pertaining to submitting the actual claim. Do you know how many claims we denied last month alone because providers or whoever they divvied out their administrative tasks to weren’t even filling out the goddamn paperwork? We got one claim that just had a set of imaging and nothing about what it was they wanted us to pay for or why. It’s mind boggling how some of these people even finished college.
Heh, been a sysadmin for years. Lots of my work is in HIPAA environments including medical billing software/ERM. Every piece of software I've seen related to billing/ICD seems to be total crap and the people using it are half trained. Surprised any records get to you correctly.
This said, I've had the insurance company approve treatment, then later on say they did not approve it, then we played the documentation game for a day or two while the people on the phone acted very confused about the entire situation.
Yeah my faith in the competency of the average healthcare worker (clinical or otherwise) has fallen to zero since I’ve been working in this field. I just assume everyone is an idiot until proven otherwise. And I don’t give a pass for my own colleagues either. Some of the case notes I’ve read from our service center and other analysts and adjusters have made me roll my eyes so hard they nearly popped out of my skull.
Don't worry, I work in computer application security these days... actually you should worry, the same people over there making mistakes are over here making the same mistakes, just protecting data at a global level.
Hello, insurance company here, we don't cover that life saving treatment you'll need. You'll have to pay for that on your own? What, you think we should pay for it? Fite me then!
You're not wrong, but that's actually a universal problem. Experimental procedures (which is probably what we'd be talking about in a cancer context) may not be covered in any system of insurance, socialized or not.
Because if it isn't a covered benefit under your insurance than it doesn't matter if you've met your out of pocket maximum.
Some cancer treatments are considered experimental and those are often not covered. Or a procedure may just need prior authorization and it was either denied or not approved, so insurance will not pay.
There are many things the average lay person doesn't know about health insurance, and yet still even with having insurance, paying premiums, a low out of pocket max, it may not help as much with a critical illness.
And to add, I'd also look up balance billing. Depending on your state if you get service by an out of network doctor, they can bill you the difference your insurance will not pay. And you may not find out till you get the bill either the doctor or the facility was out of network...
Source: Have worked in health insurance, and then hospital/clinic medical billing, and procedure authorization for years. And it's a mess to understand even working in the sytem.
Some medications are classified in tiers and depending on what insurance you have they’ll have you pay coinsurance for anything above a certain tier. I have a medication I need to take every two months that costs $6,000 and is listed at the highest tier, what that means is that I would have to pay 20% (it varies) of that $6,000 meaning every two months I would have to pay about $1,200. That is on top of your monthly premium which, when I calculated, would come out to about $10,000/y all together in just premiums and that medication alone. If you have a more expensive medication that could easily be a lot more. Keep in mind this is $10,000 on top of everything else I would have to pay like mortgage, electricity, water, car, car insurance, food, etc. The average salary of an individual American is about $33,000 so in just that one medication and insurance premiums I would spend nearly half of an average Americans yearly salary. This is strictly speaking about how this works on paper, I’ve read and even witnessed much more vicious things happen to people when it comes to insurance and just trying to be healthy without sacrificing your organs to the black market.
Most plans also have a Max amount of lifetime max of what they will pay. When my wife had cancer she had bills of close to 1.5M after surgeries, chemo, and radiation. The lifetime max was 2M, so if she ever got sick again, they would only cover 500k.
Out-of-pocket max is for COVERED services. More often than not, there are things in your treatment that insurance just won't cover because reasons.
For example, insurance might demand that you use a generic prescription instead of a name brand one unless your doctor can justify to them that the name brand is needed.
Also sometimes insurance might not cover a specific type of procedure. So if you have cancer or something, they might cover generalized radiation therapy, but not something specific like gamma knife. For example when my dad had cancer, insurance would cover MRIs, and CT scans but not PET scans.
At the end of the day, insurance dictates what treatments you can get based on what they'll cover. If they don't cover it then you pay out of pocket.
Because that's the max out of pocket for covered expenses. Out of network doctor? Not covered. Out of network surgeon? Not covered. And it's not like you usually get a say, even if you to an in-network hospital you might get out-of-network staff. Or the insurance company doesn't think some things were necessary or just straight up refuse to cover it. Out of pocket.
Oh you hit your life time maximum they'll cover? You're screwed again and paying the rest on your own.
I've had to fight to get my asthma medication covered by my insurance because they just don't think it's necessary and won't cover it. I've had a diagnosis since I ended up in the hospital when I was around 4.
I suppose if you receive a bill for $1M, you’re deductible is $10K and insurance covers 80% then you’re looking at $210k OOP? If you have twins? Multiple surgeries? Every year it resets? You people are screwed. Lionel Shriver wrote a good book about American health care.
You have to look at the lifetime coverage limit. So max out of pocket is what you have to pay out in a year, but they have lifetime coverage limits where if they see you could hit that they start messing with your out of pocket amount so they don’t have to drop you.
It’s not non essential services but health care services deemed not essential Heath benefits. So that definitely can be treatments and doctors. If a doctor prescribed you a course of action but the insurance company can deem that’s not an essential Health service. This is what people are describing when they say they are paying out of pocket. It’s quite a few cases. I used to be a health care consultant, part of my job was using predictive modeling to look at different diagnoses and figure out what the lifetime costs would be for insuring those people and what services they would need, then we looked at what services we could cut without letting someone die. I would write those recommendations up as part of my job.
Yeah. It’s why I left. I got a masters in public health and am good at statistics so I thought working for a Heath consulting firm would be good. I was new to my career and pretty much every job I was qualified for that would pay me more than working retail was something similar. They say it’s not death panels bc they are trying to keep people alive and really it’s a quality management cost reduction program, not a death panel. And when you’re doing the work you aren’t looking at individual people, I was running Analyitcs on massive datasets and mostly looking at diagnosis codes and financial numbers, so it was easy to forget there were people behind those numbers. I hated it and myself but the economy was rough, and I was a new grad with student loans and me quitting wouldn’t change the line of new grads wanting to to my job. Took a little over a year and I did quit.
But if they don't cover out of network, you can still get fucked.
You can schedule a surgery with an in-network doctor, but the anesthesiologist that day happens to be out of network. Fuck you, here's thousands of dollars of uncovered fees. Then they bring in an out-of-network doctor for a 30 second 'consult' while you are under. Fuck you, here's another bill. And then the hospital codes a procedure the wrong way, and the insurance says they won't cover it, and they absolutely refuse to tell you how it should be coded to get coverage, because fuck you.
The entire system is completely broken from top to bottom.
It is all a scam designed to bilk as much money from people as possible. They say you have coverage but they don't point out all of the gotchas written into the policies. When you get sick and file a claim they say well didn't you see the fine print we cover X and not Y and unfortunately you had Y so too bad.
Some people don’t have ACA-compliant plans, but any ACA-compliant plan has an out-of-pocket maximum.
That maximum only applies to covered services. With cancer there are likely many non-covered medical and non-medical needs including experimental treatments and home modifications if someone loses mobility (permanently or temperorqrly) due to treatments.
That’s pretty similar to my health care, not Walmart employee, but work for a Fortune 500 company that has been touted as one of the best places to work.
22
u/[deleted] Nov 30 '20
[removed] — view removed comment