Hi, I’m new to the US and health care plans, so sorry in advance if this is dumb. I’ve been reading a lot, but it’s not clear to me how out of pocket maximums apply to out-of-network providers. My employer offers several health plans, and one of the descriptions (for a HDHP PPO plan) has this (bold mine):
What is the out-of-pocket limit for this plan? For preferred providers $5,000 member/$10,000 family; for nonpreferred providers $10,000 member/$20,000 family
Of course, I will go to a preferred (in-network?) provider if I can. But I would like to make sure that I understand what will happen if I somehow end up at a nonpreferred (out-of-network) provider.
To my understanding, that line means that if I happen to go out-of-network, I will not have to pay more than $10k in a year (in other words, if I get a $100k bill, I will only pay $10k and the insurance company will pay the other $90k).
But then, they also say (bold also mine):
What is not included in the out-of-pocket limit? Premiums, balance-billing charges, health care this plan doesn’t cover, penalties for failure to obtain pre-authorization for services and the difference between the Generic Drug price and the Preferred or NonPreferred Brand Name Drug price
My understanding is that balance-billing happens when an out-of-network provider is not paid fully by the insurance company (because they want to limit themselves to paying a “reasonable” amount for a given service), and they ask me to pay the difference. If the insurance company decides that $15k is what’s reasonable for whatever service is provided, will I get balance-billed for the the remaining $85k? And how does this work with respect to the apparent out-of-pocket limit for nonpreferred providers? Will I actually be on the hook for way over the $10k out-of-network maximum?
Thanks.
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Hi, I’m new to the US and health care plans, so sorry in advance if this is dumb. I’ve been reading a lot, but it’s not clear to me how out of pocket maximums apply to out-of-network providers. My employer offers several health plans, and one of the descriptions (for a HDHP PPO plan) has this (bold mine): What is the out-of-pocket limit for this plan? For preferred providers $5,000 member/$10,000 family; for nonpreferred providers $10,000 member/$20,000 family Of course, I will go to a preferred (in-network?) provider if I can. But I would like to make sure that I understand what will happen if I somehow end up at a nonpreferred (out-of-network) provider. To my understanding, that line means that if I happen to go out-of-network, I will not have to pay more than $10k in a year (in other words, if I get a $100k bill, I will only pay $10k and the insurance company will pay the other $90k). But then, they also say (bold also mine): What is not included in the out-of-pocket limit? Premiums, balance-billing charges, health care this plan doesn’t cover, penalties for failure to obtain pre-authorization for services and the difference between the Generic Drug price and the Preferred or NonPreferred Brand Name Drug price My understanding is that balance-billing happens when an out-of-network provider is not paid fully by the insurance company (because they want to limit themselves to paying a “reasonable” amount for a given service), and they ask me to pay the difference. If the insurance company decides that $15k is what’s reasonable for whatever service is provided, will I get balance-billed for the the remaining $85k? And how does this work with respect to the apparent out-of-pocket limit for nonpreferred providers? Will I actually be on the hook for way over the $10k out-of-network maximum? Thanks.
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