For instance, if my deductible is $3,000 and my out-of-pocket maximum is listed as $6,000, is it legal for my health plan to not start counting toward the out-of-pocket max until after the deductible is reached, meaning my “maximum” is actually $9,000? (This is all for in-network, covered expenses.)
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Federally, HealthCare.gov’s glossary entry for the out-of-pocket max says: “The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.”
Does this legally apply to all plans in the U.S. now, or is it just stock language for what insurers “typically” do?
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I’m in Virginia, and the health care part of the state code is Chapter 34. Article 6 of that chapter is “Federal Market Reforms,” and the first section of that includes these definitions:
** “Cost-sharing requirement” means an enrollee’s deductible, copayment amount, or coinsurance rate.
** “Out-of-pocket maximum” or “maximum out-of-pocket” means the maximum amount an enrollee is required to pay in the form of cost-sharing requirements for covered benefits in a plan year, after which the carrier covers the entirety of the allowed amount of covered benefits under the contract of coverage.
Maybe I’m misreading and/or simply arriving at the conclusion I desire, but it sounds like Virginia law includes the deductible in the legal definition for the out-of-pocket maximum, no?
submitted by /u/-Leolo-
[link] [comments]For instance, if my deductible is $3,000 and my out-of-pocket maximum is listed as $6,000, is it legal for my health plan to not start counting toward the out-of-pocket max until after the deductible is reached, meaning my “maximum” is actually $9,000? (This is all for in-network, covered expenses.) ——— Federally, HealthCare.gov’s glossary entry for the out-of-pocket max says: “The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.” Does this legally apply to all plans in the U.S. now, or is it just stock language for what insurers “typically” do? ——— I’m in Virginia, and the health care part of the state code is Chapter 34. Article 6 of that chapter is “Federal Market Reforms,” and the first section of that includes these definitions: ** “Cost-sharing requirement” means an enrollee’s deductible, copayment amount, or coinsurance rate. ** “Out-of-pocket maximum” or “maximum out-of-pocket” means the maximum amount an enrollee is required to pay in the form of cost-sharing requirements for covered benefits in a plan year, after which the carrier covers the entirety of the allowed amount of covered benefits under the contract of coverage. Maybe I’m misreading and/or simply arriving at the conclusion I desire, but it sounds like Virginia law includes the deductible in the legal definition for the out-of-pocket maximum, no? submitted by /u/-Leolo- [link] [comments]Read Morer/HealthInsurance