Author Topic: Please Explain Health Insurance Deductible vs. OOP Max to me!  (Read 3269 times)


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Every time that I think I have a good grasp on how health insurance works, I find that I don't. After GRS went fishing for comments with their "Ask the Reader" post yesterday, I looked into my own health insurance and how it's actually been covering me so far this year.

I am an independent contractor, and purchased a shiny gold Obamacare plan this year because I'm pregnant. The deductible is $1000, and the Individual Out of Pocket Maximum is $4500. The insurance pays 20% for in-network services.

So far this year I've been responsible for about $400 total of my health expenses, with Premera picking up the other $1600 for ultrasounds, blood work, etc. meaning that I'm paying 20% of what they allow me to be charged. When I look at my account online, it shows that this expense has been counted towards my out of pocket maximum, but not against my deductible? I also looked at my son's account. He's had a well-baby check up which was 100% covered and a prescription that cost us $10. The $10 is being counted towards his OOP Max, but also not towards his deductible. So I'm confused about what counts towards the deductible?

My mom is a doctor, and my dad is a right wing nut. He's done a lot of complaining this year that they're going to go broke because no one is going to the doctor anymore because their OOPs are so high that they can't afford it, and when I tried to Google an answer to my question, I found a lot of posts about how you pay for 100% of your health expenses until you hit your deductible, but clearly that doesn't seem to be the case for me. I pay only my 20% portion, and presumably if/when I hit the OOP Max, I won't pay anything...right? And what happens when/if I hit my deductible?

Thanks in advance for helping me figure this out!

southern granny

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Re: Please Explain Health Insurance Deductible vs. OOP Max to me!
« Reply #1 on: April 12, 2014, 08:41:28 PM »
There are a lot of different plans, but the way mine works is I pay a $25 copay for office visits.  Sounds like you pay 20% of office visits.  Preventive visits such as exams, immunizations, flu shots are all paid by insurance at 100%, that is an ACA requirement.  My deductible is $600 which probably won't come into play except for a hospitalization.  If I go into the hospital, I have to pay all of the first $600 (my deductible), then I pay %20 of everything over the $600 deductible until I hit my OOP, which in my case is $2000 (above the deductible).  So supposedly, If I am in the hospital for several days, the most it should cost me is $2600.  My plan is through my employer. 

La Bibliotecaria Feroz

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Re: Please Explain Health Insurance Deductible vs. OOP Max to me!
« Reply #2 on: April 13, 2014, 06:03:20 AM »
First, congratulations!

I had a plan once in which certain services were subject to a 20% copay, but were NOT subject to the deductible. Sounds like that may be the case with some of your maternity services. If you went to, say, an allergist

You're saving up for the OOP, right? Because I think even if ALL your maternity services are no deductible, there's a good chance that your hospital stay will put you over, especially if anything gets complicated. (I was glad that I had good coverage when I get the Explanation of Benefits from the anesthesiologists...and it was $16000!)

Weedy Acres

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Re: Please Explain Health Insurance Deductible vs. OOP Max to me!
« Reply #3 on: April 13, 2014, 08:05:43 AM »
There are some health plans (those linked with HSAs) where all healthcare expenses--doctor visits, hospital stays, prescription drugs--are subject first to the deductible and then are 100% covered after that.  It doesn't sound like this is what you've got.

It sounds like yours has a deductible that is then 80% is covered after that until you meet your OOP max.  However, there are still some services that are carved out from that and covered at a different rate.  Preventive care is often 100% covered, and it sounds like OB prenatal care is covered 80%.  In that case, you plug along paying 20% instead of 100%.  But if you broke your leg or took a trip to the ER, you'd pay the whole thing until you maxed out your deductible.  It's also common for prescription coverage to be on a separate plan with copays instead of lumped in with the rest of expenses for purpose of deductibles.

In any case, everything you spend (deductible, copays, etc.) accumulates to your OOP max.  Once you reach that, you're 100% covered.

You might try reading your plan benefit summary to see what services have separate deductibles/copays.


  • Walrus Stache
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Re: Please Explain Health Insurance Deductible vs. OOP Max to me!
« Reply #4 on: April 13, 2014, 07:56:36 PM »
Right now I'm looking at insurance and I'm not sure how I can tell whether a high-deductible plan makes sense when prices aren't, like, published.  It's always been an easy decision for me, because I never go to the doctor.  But I'm looking for someone else and it's aggravating...


  • Stubble
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Re: Please Explain Health Insurance Deductible vs. OOP Max to me!
« Reply #5 on: April 14, 2014, 07:26:23 AM »
Finally a thread I can contribute to!

Generally if you have a plan with copays, they will apply to your office visits and some specialty services and your hospital care will require a deductible first and then coinsurance(they pay X% you pay y%) after that until you hit your out of pocket maximum.

With a high deductible plan, there are usually no copays at all and every bit of care you use is reduced to pay according to the insurance companies contract with the provider and then it will apply first to your deductible and then to coinsurance until you hit the OOP max.

In some plans the prescription costs apply to the deductible and in some they do not.  I see now that Weed Acres already answered this very well. There should have been a Summary plan document available when you enrolled(though often hard to find), but if you log into your providers website you should be able to find a copy and it will detail which bucket everything flows into.


  • Stubble
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Re: Please Explain Health Insurance Deductible vs. OOP Max to me!
« Reply #6 on: April 14, 2014, 09:06:54 AM »
I don't know how you all managed to respond this weekend while the site was down (I created a forum account, posted a question, and then boom - I'm pretty sure I broke MMM) but it was awesome to log in and see all these answers this morning!

Thanks for the congrats, frugalparagon! And yes, we're prepared to reach the total out of pocket maximum if worst comes to worst. I paid slightly less than my OOP Max for a hospital birth with my son with no issues or anesthesia (the bill was around $15,000) and if all stays healthy with this pregnancy we're planning on a home birth with a midwife (and a bill total around $5000) so my costs should remain much lower.

I guess I'd have to break out the actual benefits plan booklet to get all the little details, but the benefits summary available online shows that I'm really very well covered - everything from ambulances to emergency room visits to outpatient surgery is covered at 80% with me being responsible for 20%. This includes maternity/labor as well as "inpatient facilities" (hospital stays?) so it seems like almost everything in network is covered by coinsurance. It does say that office visits may be subject to copay, deductible or coinsurance depending on the visit, but it seems like given how little applies to the deductible it would be very hard to reach. Thanks Weedy Acres and Bourbon, and good luck making a decision dragoncar!