Tuesday, October 12, 2021

Maxing out

My head is hurting trying to figure out how this deductible, co insurance, and max out of pocket works. Not to mention reviewing all these EOB's (explanation of benefits). We've never ever had to meet our deductible or max out of pocket before, so this is new to me to figure out. Yesterday I got a call from the surgeons office letting me know what the charge will be for the surgeon himself. Apparently she had already gotten the info from his insurance on how much his deductible has been met so far. She said $5402 (from his endoscopy and dr visits). His deductible with this ACA Bronze plan I started on 9/1 is $8500 and his out of pocket max is $8550. 

With this surgeon office lady telling me how much deductible and out of pocket max he's met so far, she said something I didn't know! The deductible applies towards the out of pocket max! I thought they were 2 separate amounts. I thought he had to pay out his deductible of $8500 and then pay out another $8550 for the out of pocket max, but its a max for the year of $8550, including the deductible. Boy, that sure made me happy to hear (and I verified that's how it works online). Whew!.

So, the most this surgery is going to cost is the remaining amount left in the out of pocket max to meet, which is $3148. The hospital mychart has this "estimate" feature. For the endoscopy they just did it automatically and put it in a mychart message. I haven't seen one yet for the surgery, but I was able to get one online myself and the hospital charge will be about $13,000. The surgeon office lady said the surgeon's fee will be a little over $1000, so $14,000 total. But we will only owe the $3148, because he will have met his out of pocket max for the year. Any doctors or medical bills after this $8550 is supposed to be paid in full by the insurance for the rest of the year.

At least I think that's how I'm understanding it all now! So, then I was like hey, if the deductible is part of the "out of pocket max" - why didn't it work the same way with his previous short term insurance? But, apparently they worded it different in that it's a deductible and a "co-insurance" out of pocket max, so that in this case they really are 2 separate amounts to deal with to meet the max for each. Bummer, but that's what I have been expecting all along, so at least it wasn't a bad surprise. The new insurance info was a good surprise.

I wanted to get online with his new insurance company to view claims, but apparently needed an activation code to create the account. I could not find one in any of the paperwork they had sent so far. I called and, of course, since the insurance is in dh's name and they didn't have me on file to talk to, they couldn't give it to me. And, of course, right when I called dh was outside using the leaf blower, so I said I'd call back later. Once he came back inside I called and he authorized them to talk to me today for the activation code and she also emailed me the form so I can permanently be on file to talk with them about his benefits and claims. He certainly won't want to do it, nor understand how any of it is supposed to work.

I then activate his insurance account and get online and see they have processed 2 claims so far and 2 others are still being processed. They have processed the hospital and dr charges for the endoscopy. One of the ones pending processing is from our local town hospital. That must be for the blood work he had to go back for. The other is for the anesthesiologist with the endoscopy. It is strange that a claim from the urologist office visit isn't showing. You'd think they would have submitted their claim by now (appt was from mid Sept).

Dh is off to drive back into the city for his 3rd Covid brain stab. I'm staying home. It's payroll processing day.


  1. When I started reading and saw the amounts of the out-of-pocket and the deductible I also thought they were BOTH payable and nearly fainted! Even so, $8,000+ out-of-pocket still gives me palpitations - but I guess at least it's better than $16,000+!

    1. yes, for sure. I guess in 2021 the max out of pocket on an ACA plan is $8550. I could have chosen a plan with a lower oop max (I think) but then premiums are way high and already now paying $650 a month for his plan.

  2. Have your husband go get as much medical stuff done as he can before the end of the year!

    1. that's the plan. He also needs to have a prostate biopsy done, so we will get that done, too.