The Affordable Care Act’s Out of Pocket Maximum isn’t what you’d expect, at least not in Washington State. My health insurer’s website advertises mine as, “The maximum amount you could have to pay in a year for covered services from in-network providers.” It seems simple and clear but instead it’s insurance fraud.

Out of Pocket Maximum

Lifewise Plan Marketing for Out of Pocket Maximum

Treatment related to my recently discovered brain tumor quickly pushed me over my out of pocket maximum for the year. After spending $12,505 in premiums and my share of covered services, I’m currently treated as uninsured when it comes to outpatient rehabilitation, physical therapy, chiropractic and soon, other services.

I’ve exceeded my out of pocket maximum yet am still paying out of my pocket for health care.

What’s Going On?

The website defines the Out of Pocket Maximum as “The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits.” That’s where the wiggle room begins for insurers.

Legislators in each state write the laws which determine the local definition of “essential health benefits.” Of course, health insurance lobbyists play a role in how these benefits are defined.

As an example, in Washington State, insurers limit outpatient rehabilitation to 25 visits. Once that’s exceeded, not only do you have to pay out of pocket, you’re considered uninsured for any treatment of this kind. Not only am I currently paying for necessary care out of pocket but I no longer have related contractual protections from my insurance policy, such as limits on provider rates.

My out of pocket maximum is $4,500 but I’ve actually had to spend more than $32,500 on healthcare this year.

Deductibles Are Ignored

You might be asking, well, what about my deductible? It’s excluded too.

The website defines Deductible as, “The amount you owe for covered health care services before your health insurance or plan begins to pay.”

Ironically, in Seattle, it takes about 25 visits of physical therapy to exceed most deductibles — right about at which time, you’re considered uninsured for further treatment of this kind.

Additionally, the calculation of deductibles also excludes your other out of pocket costs such as premiums, co-pays, coinsurance and fees above allowed amounts. And, there’s a completely separate deductible for when you visit out of network providers.

Misleading Consumers

Misleading consumers by contorting the terms Deductible and Out of Pocket Maximum seems nothing more than fraudulent advertising to me. Why does the state’s Office of Insurance Commissioner (OIC) allow the insurers to sell policies using this terminology?

Recently, the OIC wrote me:

I’m sorry if out-of-pocket maximums and benefit maximum limits are confusing to you. … Benefit maximum limits are unrelated to the out-of-pocket maximums. Out-of-pocket maximum is the limit you pay on covered services. Once you exceed the benefit maximum limit, it is no longer a covered service; therefore, it is not subject to the out-of-pocket maximum. Once these limits are met, further services will not be covered regardless of the out-of-pocket maximum or medical necessity.

George Orwell couldn’t have said it better. If you’re a highly paid insurance executive, it’s doubleplusgood for now — until we fire them and extend Medicare into a single payer plan for everyone.

Insured members are allowed to file appeals which I plan to do this year. However, the more incapacitated you are, the less likely you are capable of managing the paperwork required to take on your insurer’s bureaucracy. The most vulnerable are most at risk.

The OIC is tasked with protecting consumers and making sure that insurers and their policies comply with the law but I’ve found them to be mostly passive rubber stampers. Instead, they encouraged me, “to petition [my] local and federal legislators to enact law requiring insurance companies to not have benefit maximum limits on certain services in their health plans.”

When I interviewed Rep. Eileen Cody, Chair of the Healthcare and Wellness Committee last year, she doubted the Legislature would ever do this. She referred me to a report showing that Washington, like most states, receives an F in healthcare pricing transparency.

One side-effect of my brain tumor is that it’s reminded me that my time on earth is limited and made me increasingly focused on what matters most – primarily for me, that’s recognizing that the only way to restore our democracy is for all of us to begin working together to overturn our current government and its integrated system of corruption — just as our state’s namesake George Washington would expect us to. I’ll be writing more about this soon.

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Posted by Jeff Reifman

Jeff is a technology consultant based in the Pacific Northwest.

One Comment

  1. I am running into a similar situation with physical therapy (fortunately not quite as bad). The out-of-pocket maximum makes little to no sense, especially when it comes to outpatient rehabilitation. There are definitely many people out there who would be unable to undergo major surgeries or stuck with bills they can’t pay because they didn’t completely understand their insurance policy when they started.


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